Texas Standard Prior Authorization Request Form · PDF fileTexas Standard Prior Authorization...

Click here to load reader

  • date post

  • Category


  • view

  • download


Embed Size (px)

Transcript of Texas Standard Prior Authorization Request Form · PDF fileTexas Standard Prior Authorization...

  • Texas Standard Prior Authorization Request Form for Prescription Drug Benefits

    NOFR002 | 0615 Texas Department of Insurance

    Please read all instructions below before completing this form. Please send this request to the issuer from whom you are seeking authorization. Do not send this form to the Texas

    Department of Insurance, the Texas Health and Human Services Commission, or the patients or subscribers employer.

    Beginning September 1, 2015, health benefit plan issuers must accept the Texas Standardized Prior Authorization Request Form for Prescription Drug Benefits if the plan requires prior authorization of a prescription drug or device.

    In addition to commercial issuers, the following public issuers must accept the form: Medicaid, the Medicaid managed care program, the Childrens Health Insurance Program (CHIP), and plans covering employees of the state of Texas, most school districts, and The University of Texas and Texas A&M Systems.

    Intended Use: Use this form to request authorization by fax or mail when an issuer requires prior authorization of a prescription drug, a prescription device, formulary exceptions, quantity limit overrides, or step-therapy requirement exceptions. An Issuer may also provide an electronic version of this form on its website that you can complete and submit electronically, through the issuers portal, to request prior authorization of a prescription drug benefit.

    Do not use this form to: 1) request an appeal; 2) confirm eligibility; 3) verify coverage; 4) request a guarantee of payment; 5) ask whether a prescription drug or device requires prior authorization; or 6) request prior authorization of a health care service.

    Additional Information and Instructions: Section I Submission: Enter the name and contact information for the issuer or the issuers agent that manages or administers the issuers prescription drug benefits, as applicable. An issuer or agent may have already prepopulated its contact information on the copy of this form posted on its website.

    Section VI Prescription Compound Drug Information: List the quantities of ingredients in units of measure (mg, ml, etc.).

    Section VIII Patient Clinical Information: Enter ICD Version 9 or 10, as applicable.

    Section IX Justification: In the space provided or on a separate page: Provide pertinent clinical information to justify requests for initial or ongoing therapy, or increases in current

    dosage, strength, or frequency. Explain any comorbid conditions and contraindications for formulary drugs. Provide details regarding titration regimen or oncology staging, if applicable. Provide pertinent information about any step-therapy exception, if applicable.

    Attach supporting clinical documentation (medical records, progress notes, lab reports, etc.), if needed.

    Note: Some issuers may require more information or additional forms to process your request. If you think more information or an additional form may be needed, please check the issuers website before faxing or mailing your request.

    Texas Department of Insurance | 333 Guadalupe | Austin, Texas 78701 | (800) 578-4677 | www.tdi.texas.gov | @TexasTDI


    SECTION I SUBMISSION Submitted to: Phone: Fax: Date:

    SECTION II REVIEW Expedited/Urgent Review Requested: By checking this box and signing below, I certify that applying the standard review time frame may seriously jeopardize the life or health of the patient or the patients ability to regain maximum function.

    Signature of Prescriber or Prescribers Designee: __________________________________________________________________


    Other Unknown Address: City: State: ZIP Code:

    Issuer Name (if different from Section I): Member or Medicaid ID #: Group #:

    BIN # (if available): PCN (if available): Rx ID # (if available):


    Address: City: State: ZIP Code:

    Phone: Fax: Office Contact Name: Contact Phone:

    SECTION V PRESCRIPTION DRUG INFORMATION (If this is a compound drug, identify all ingredients in Section VI, below.)

    Requested Drug Name:

    Strength: Route of Administration: Quantity: Days Supply: Expected Therapy Duration:

    To the best of your knowledge this medication is:

    New therapy Continuation of therapy (approximate date therapy initiated: _________________________________ ) For Provider Administered Drugs Only:

    HCPCS Code: ________________________ NDC #: ________________________ Dose Per Administration: _________________


    Compound Drug Name:

    Ingredient NDC # Quantity Ingredient NDC # Quantity

    NOFR002 | 0615 Page 2 of 3

  • SECTION VII PRESCRIPTION DEVICE INFORMATION Requested Device Name: Expected Duration of Use: HCPCS Code (If applicable):

    SECTION VIII PATIENT CLINICAL INFORMATION Patients diagnosis related to this request: ICD Version: ICD Code:

    (Provide the following information to the best of your knowledge) Drugs patient has taken for this diagnosis:

    Drug Name Strength Frequency Dates Started and Stopped or Approximate Duration Describe Response, Reason

    for Failure, or Allergy

    Drug Allergies: Height (if applicable): Weight (if applicable):

    Relevant laboratory values and dates (attach or list below): Date Test Value


    NOFR002 | 0615 Page 3 of 3

    /ColorImageDict > /JPEG2000ColorACSImageDict > /JPEG2000ColorImageDict > /AntiAliasGrayImages false /CropGrayImages false /GrayImageMinResolution 150 /GrayImageMinResolutionPolicy /OK /DownsampleGrayImages true /GrayImageDownsampleType /Bicubic /GrayImageResolution 225 /GrayImageDepth -1 /GrayImageMinDownsampleDepth 2 /GrayImageDownsampleThreshold 1.33333 /EncodeGrayImages true /GrayImageFilter /DCTEncode /AutoFilterGrayImages true /GrayImageAutoFilterStrategy /JPEG /GrayACSImageDict > /GrayImageDict > /JPEG2000GrayACSImageDict > /JPEG2000GrayImageDict > /AntiAliasMonoImages false /CropMonoImages false /MonoImageMinResolution 300 /MonoImageMinResolutionPolicy /OK /DownsampleMonoImages true /MonoImageDownsampleType /Bicubic /MonoImageResolution 225 /MonoImageDepth -1 /MonoImageDownsampleThreshold 1.33333 /EncodeMonoImages true /MonoImageFilter /CCITTFaxEncode /MonoImageDict > /AllowPSXObjects true /CheckCompliance [ /None ] /PDFX1aCheck false /PDFX3Check false /PDFXCompliantPDFOnly false /PDFXNoTrimBoxError true /PDFXTrimBoxToMediaBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXSetBleedBoxToMediaBox true /PDFXBleedBoxToTrimBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXOutputIntentProfile (U.S. Web Coated \050SWOP\051 v2) /PDFXOutputConditionIdentifier (CGATS TR 001) /PDFXOutputCondition () /PDFXRegistryName (http://www.color.org) /PDFXTrapped /False

    /CreateJDFFile false /Description > /ExportLayers /ExportVisibleLayers /Namespace [ (Adobe) (Common) (1.0) ] /OtherNamespaces [ > /FormElements false /GenerateStructure true /IncludeBookmarks true /IncludeHyperlinks true /IncludeInteractive false /IncludeLayers false /IncludeProfiles true /MarksOffset 6 /MarksWeight 0.250000 /MultimediaHandling /UseObjectSettings /Namespace [ (Adobe) (CreativeSuite) (2.0) ] /PDFXOutputIntentProfileSelector /UseName /PageMarksFile /RomanDefault /PreserveEditing false /UntaggedCMYKHandling /UseDocumentProfile /UntaggedRGBHandling /UseDocumentProfile /UseDocumentBleed false >> > ]>> setdistillerparams> setpagedevice

    Submitted to Phone Number: Submitted to Fax Number: Date Submitted: ExpeditedUrgent Review Requested: Patient's Name: Patient's Phone Number: Patient's Date of Birth: Patient's Gender - Male: Patient's Gender - Female: Patient's Gender - Other: Patient's Gender - Unknown: Patient's Address - Street: Patient's Address - City: Patient's Address - State: Patient's Address - ZIP Code: Issuer Name if different from Section I: Member or Medicaid ID Number: Group Number: BIN Number (if available):: PCN (if available):: Rx ID Number if available: Prescriber's Name: Prescriber's NPI Number: Prescriber's Specialty: Prescriber's Address - Street: Prescriber's Address - City: Prescriber's Address - State: Prescriber's Address - ZIP Code: Prescriber's Phone Number: Prescriber's Fax Number: Prescriber's Office Contact Name: Prescriber's Office Contact Phone Number: Requested Prescription Drug Name: Requested Prescription Drug Strength: Requested Prescription Drug Route of Administration: Requested Prescription Drug Days Supply: Requested Prescription Drug Expected Therapy Duration: New therapy: Continuation of therapy: If continuation of therapy, approximate date therapy initiated: For Provider Administered Drugs Only - NDC Number: For Provider Administered Drugs Only - Dose Per Administration: For Provider Administered Drugs Only - HCPCS Code: Compound Drug Name: Compound Drug Ingredient 1: Ingredient 1 NDC Number: Quantity of Ingredient 1: Compound Drug Ingredient 8: Ingredient 8 NDC Number: Quantity of Ingredient 8: Compound Drug Ingredient 2: Ingredient 2 NDC Number: Quantity of Ingredient 2: Compound Drug Ingredient 9: Ingredient 9 NDC Number: Quantity of Ingredient 9: Compound Drug Ingredient 3: Ingredient 3 NDC Number: Quantity of Ingredient 3: Compound Drug Ingredient 10: Ingredient 10 NDC Number: Quantity of Ingredient 10: Compound Drug Ingredient 4: Ingredie