Texas health plans that require prior authorization of a prescription drug or device must accept this standard request, which prescribers fax or mail to the plan or its PBM. Besides prior authorization, it covers formulary exceptions, quantity limit overrides and step-therapy exceptions. Commercial issuers, Medicaid and its managed care plans, CHIP, and state employee, school district, UT and Texas A&M plans all must take it.
The prescriber or the prescriber's office completes Sections II through IX. Section I names the issuer or its pharmacy benefit agent and may already be filled in on the copy posted on the issuer's website; the Section II signature line is for the prescriber or the prescriber's designee.
Enter the name, phone, fax and date for the issuer, or for the agent that manages or administers its prescription drug benefits. An issuer or agent may have prepopulated its contact information on the copy posted on its website, so start from the plan's own copy when one exists. This tells you where to fax or mail the request.
Check Expedited/Urgent Review Requested only when applying the standard review time frame may seriously jeopardize the patient's life, health or ability to regain maximum function. Checking the box takes the signature and date of the prescriber or the prescriber's designee, which certifies that statement. Leave the box unchecked for routine requests.
Enter the patient's name, phone, date of birth and sex (Male, Female, Other or Unknown), plus street address, city, state and ZIP code. If the issuer differs from the one named in Section I, give its name here. Add the member or Medicaid ID number and the group number so the issuer can match the request to the right coverage.
Give the prescriber's name, NPI, specialty, address, phone and fax, and the office contact name and contact phone. The issuer uses these details to reach the office with questions and to return its decision, so list a fax line and contact person who can respond during the review period.
Enter the requested drug name, strength, route, quantity, days' supply and expected therapy duration. Mark new therapy or continuation, with the approximate start date, and for continuation confirm adherence and effectiveness. For provider-administered drugs, add the HCPCS code, NDC and dose per administration. For a compound drug, list all ingredients in Section VI instead of here.
Name the compound and list each ingredient with its NDC number and quantity. The instructions require quantities in units of measure such as mg or ml, so write the unit with every amount. Complete this section only when the request is for a compound; a single-ingredient drug is fully described in Section V.
For a prescription device, enter the requested device name, the expected duration of use and, if applicable, its HCPCS code. Issuers that require prior authorization of a prescription device must accept this form for it, so a device request does not need a separate service form such as NOFR001.
Give the diagnosis related to the request with the current ICD version and code. List drugs the patient has taken for this diagnosis with strength, frequency, dates started and stopped or approximate duration, and the response, reason for failure or allergy. Add height and weight if applicable, drug allergies, and relevant laboratory values with dates, or attach them.
In the space or on a separate page, provide clinical information justifying initial or ongoing therapy or an increase in dosage, strength or frequency. Explain comorbid conditions and contraindications to formulary drugs, give titration regimens or oncology staging if applicable, and give the details for any step-therapy exception under Insurance Code Section 1369.0546(c). Attach medical records, progress notes or lab reports if needed.
Download the current version from the source each time; forms change without notice.
Texas Standard Prior Authorization Request Form for Prescription Drug Benefits
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Yes. Besides commercial issuers, the form lists Medicaid, the Medicaid managed care program, CHIP, and plans covering employees of the state of Texas, most school districts, and The University of Texas and Texas A&M Systems as issuers that must accept it when they require prior authorization of a prescription drug or device.
No. The instructions list six things the form is not for: requesting an appeal, confirming eligibility, verifying coverage, requesting a guarantee of payment, asking whether a drug or device needs prior authorization, and requesting prior authorization of a health care service. Use the issuer's appeal process for a denial.
Complete Section IX, Justification, with pertinent information about the exception, citing the grounds in Texas Insurance Code Section 1369.0546(c). Section IX is required for a step-therapy exception even when the request is for continuation of therapy. Attach supporting records if needed.
The only signature line is in Section II. The prescriber or the prescriber's designee checks the expedited or urgent review box, then signs and dates to certify that the standard review time frame may seriously jeopardize the patient's life, health or ability to regain maximum function.