CurrentBaylor Scott & White Health PlanPolicy N/A

Texas Standard Prior Authorization Request Form for Prescription Drug Benefits

This document provides the standard Texas prior authorization request form and instructions for requesting authorization of prescription drugs, devices, formulary exceptions, quantity limit overrides, and step-therapy exceptions from health plan issuers and certain public programs. It affects providers submitting prior authorization requests and issuers/agents who must accept the Texas standard form.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyTexas Standard Prior Authorization Request Form for Prescription Drug Benefits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionUse this form to request prior authorization and send the completed form to the issuer or the issuer's agent.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Sections I-IXform sections included (Submission through Justification)

Medicaid/CHIP & state planspublic issuers required to accept form

PA / formulary / qty / stepintended uses

Not for appeals/eligibilityexplicitly excluded uses

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Required information and procedural criteria

Information required to support authorization requests and exceptions:

ALL of the following

Patient Information: identify the patient; include height/weight when applicable and relevant demographic details as requested.
Prescriber Information: include prescriber name, contact details, and signature as required for expedited review attestation.
Prescription Drug Information: provide requested drug name, strength, route of administration, quantity, days' supply, expected therapy duration, and indicate whether this is new therapy or continuation of therapy; include HCPCS and NDC when applicable and dose per administration for provider-administered drugs.
Compound Drug Details (if compound): list each ingredient name, associated NDC when available, and quantity of each ingredient in units of measure (mg, mL, etc.).
Patient Clinical Information: supply diagnosis, relevant laboratory values and dates, drug allergies, and list drugs the patient has taken for this diagnosis.
Justification: provide pertinent clinical information to justify initial or ongoing therapy or dose/frequency increases; explain comorbid conditions and contraindications to formulary drugs; include titration regimen or oncology staging when applicable; for step-therapy exception requests, provide the step-therapy rationale and supporting details; attach supporting clinical documentation (medical records, progress notes, lab reports) as needed.
Continuation of therapy process: for continuation requests (except step-therapy exceptions), Sections VIII or IX need not be completed unless there has been a material change in previously provided information; Section IX is required for step-therapy exception requests.
Submission destination and process: send the completed form to the issuer or the issuer's agent (not to the Department of Insurance, HHSC, or employer); check the issuer's website for additional required information or forms and follow issuer-provided submission channels (electronic, fax, or mail).
Expedited/Urgent review attestation: if expedited/urgent review is requested, the prescriber must check the expedited review box and sign attesting that the standard review timeframe may seriously jeopardize the patient's life, health, or ability to regain maximum function.
Prohibited uses: do not use this form to request an appeal, confirm eligibility, verify coverage, request a guarantee of payment, ask whether a drug requires authorization, or to request authorization of a non-drug health care service.

Drug Coding and Compound Quantities

Drug coding fieldsmixed

HCPCS	Field for HCPCS code for provider-administered drugs
NDC	Field for NDC number for provider-administered drugs and compound ingredients

inv-03: Compound ingredient quantities

InstructionList the quantities of compound ingredient(s) in units of measure such as mg or mL as part of Section VI: Prescription Compound Drug Information.

Required fields (examples)Ingredient name, corresponding NDC (when applicable), and the specific quantity for each ingredient (expressed in mg, mL, etc.).

Multiple ingredientsProvide each compound ingredient as a separate line item (Compound Drug Name 1–5 and Ingredient 1–5 fields shown on the form).

Where entered on formSection VI — Prescription Compound Drug Information includes separate fields for Compound Drug Name entries and ingredient/NDC/quantity fields.

How to Submit Requests and Provider Responsibilities

Prior Authorization

How to submit prior authorization requests

Use this form to request prior authorization of a prescription drug or device, formulary exceptions, quantity limit overrides, or step-therapy requirement exceptions; send the completed form to the issuer or issuer's agent (do not send to the Department of Insurance, HHSC, or the employer).

Prior Authorization

Expedited/Urgent review attestation

If expedited/urgent review is needed, the prescriber (or designee) must check the Expedited/Urgent Review box and sign and date attesting that the standard review timeframe may seriously jeopardize the life or health of the patient or the patient's ability to regain maximum function.

Denial Risk

Prohibited uses of this form

Do not use this form to request an appeal, confirm eligibility, verify coverage, request a guarantee of payment, ask whether a prescription drug or device requires authorization, or request authorization of a health care service.

Documentation Required

Accepted submission channels

Issuers may provide an electronic version of the Texas standard form on their website, or accept completed forms submitted by fax or mail to the issuer or the issuer's agent.

Form Definitions

inv-08: Texas Standard Prior Authorization Request Form for Prescription Drug Benefits

DefinitionTexas Standard Prior Authorization Request Form for Prescription Drug Benefits — the standardized form issuers must accept for prior authorization requests for prescription drugs or devices, including formulary exceptions, quantity limit overrides, and step-therapy exceptions.

Regulatory basisRequired under TDI rule 28 TAC Section 19.1820 for applicable commercial and specified public issuers (Medicaid, Medicaid managed care, CHIP, state and many education system plans).

Intended usesTo request prior authorization by fax or mail or electronically (if the issuer provides an online version) when an issuer requires authorization for a prescription drug, device, formulary exception, quantity limit override, or step-therapy exception.

Not forNot to be used to request appeals, confirm eligibility, verify coverage, request guarantees of payment, ask whether a drug requires authorization, or request authorization of a health care service.

inv-09: Expedited/Urgent Review

Form locationSection II — Review includes the Expedited/Urgent Review checkbox and signature/date fields.

OpenPayer

Texas Standard Prior Authorization Request Form for Prescription Drug Benefits

Required Information and Coverage Criteria

Drug Coding and Compound Quantities

How to Submit Requests and Provider Responsibilities

Form Definitions