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Blank Texas Pre Authorization Request PDF Template

The Texas Pre Authorization Request form is a crucial document used to seek approval for specific medications under Texas Medicaid, particularly for Global Prescription Exceptions. This form ensures that patients receive necessary treatments while adhering to state regulations and guidelines. By following the outlined steps and providing accurate information, healthcare providers can facilitate a smoother authorization process for their patients.

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Blank Texas Pre Authorization Request PDF Template

Contents

Form Example

Prior Authorization Form for Texas Medicaid

Global Prescription Exceptions (Medicaid)

This fax machine is located in a secure location as required by HIPAA regulations.

Complete/review information, sign and date. Fax signed forms to Caremark at 1‐866‐255‐7569.

Please contact Caremark at 1‐877‐440‐3621 with questions regarding the prior authorization process.

When conditions are met, we will authorize the coverage of Global Prescription Exceptions.

Drug Name:

Patient Name:

Patient ID:

Patient Group Number: Patient Date of Birth:

Physician Name:

Physician Phone:

Physician Fax:

Physician Address: City, State ZIP:

Patient Information

Prescribing Physician

Diagnosis:

ICD Code:

Please circle the appropriate answer for each question.

1.	If this is an office‐administered injectable drug…
	A. Is your intent to provide and bill for this medication? OR	Y	N
	B. Is your intent to have it provided through a pharmacy?	Y	N
		Y	N

2.	Is the requested drug being used for an FDA‐approved indication?	Y	N
	[If the answer to this question is yes, then skip to Question 4.]

3.Is the requested drug being used for an indication that is supported by information from

the appropriate compendia of current literature (e.g., AHFS, Micromedex, current	Y	N
accepted guidelines, etc.)?

4. Has the patient demonstrated a failure of or intolerance to a majority (not more than three)	Y	N
of the preferred formulary or preferred drug list alternatives for the given diagnosis?	Y	N

5.Is the drug being prescribed within the manufacturer's published dosing guidelines, or

does it fall within dosing guidelines found in the compendia of current literature (e.g.,	Y	N
package insert, AHFS, Micromedex, current accepted guidelines, etc.)?

6. Is the drug being prescribed for a medically accepted indication that is recognized as a	Y	N
covered benefit by the applicable health plan's program?	Y	N
covered benefit by the applicable health plan's program?

Comments:

I affirm that the information given on this form is true and accurate as of this date.

Prescriber (or authorized) Signature and Date

PF‐TX‐0003‐12

March 2012

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Common mistakes

Incomplete Patient Information: Failing to fill out all required fields such as Patient Name, Patient ID, and Date of Birth can lead to delays in processing. Ensure all sections are complete before submission.
Incorrect Physician Details: Providing inaccurate or outdated information for the prescribing physician, including their name, phone number, or fax number, can hinder communication. Double-check these details to avoid complications.
Neglecting to Answer Questions: Skipping questions, especially those regarding the drug's intended use and FDA approval, can result in automatic denial of the request. Carefully read and respond to each question.
Missing Signature and Date: Not signing or dating the form may invalidate the request. Always ensure that the prescriber or authorized person has signed and dated the form before faxing it.

Key takeaways

When filling out the Texas Pre Authorization Request form, it is essential to keep several key points in mind to ensure a smooth process.

Complete All Required Information: Ensure that every section of the form is filled out accurately. Missing information can delay the authorization process.
Understand the Questions: Carefully read each question, especially those regarding the drug's usage and the patient's medical history. Your answers must reflect the patient's situation accurately.
Follow Submission Guidelines: After signing and dating the form, fax it to Caremark at the designated number. Confirm that the fax is sent to a secure location to comply with HIPAA regulations.
Seek Assistance if Needed: If you have questions about the prior authorization process, do not hesitate to contact Caremark for clarification. Their support can help you navigate any uncertainties.

⇓ Texas Pre Authorization Request PDF

Steps to Using Texas Pre Authorization Request

After completing the Texas Pre Authorization Request form, it is essential to send it to Caremark for processing. Make sure all sections are filled out accurately to avoid delays. You can contact Caremark if you have any questions regarding the prior authorization process.

Obtain the Texas Pre Authorization Request form.
Fill in the Drug Name field with the name of the medication.
Enter the Patient Name, Patient ID, and Patient Group Number.
Provide the Patient Date of Birth.
Complete the Physician Name, Physician Phone, Physician Fax, and Physician Address sections.
Include the City, State ZIP for the physician's address.
Document the Prescribing Physician Diagnosis and the ICD Code.
Answer the questions regarding the drug and its intended use by circling Y for yes or N for no.
Provide any necessary comments in the comments section.
Sign and date the form in the designated area.
Fax the signed form to Caremark at 1-866-255-7569.