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Do not send it to the Texas Department of Insurance, the Texas Health and Human Services Commission, or the patient’s or subscriber’s employer.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What requests is the form intended to support?",{"text":68,"@type":64},"Use it to request authorization by fax or mail when prior authorization is required for a prescription drug or device, formulary exceptions, quantity limit overrides, or step-therapy requirement exceptions.",{"name":70,"@type":61,"acceptedAnswer":71},"What information must be included for the clinical and justification sections?",{"text":72,"@type":64},"Provide pertinent clinical information to justify initial or ongoing therapy and any increases in dosage, strength, or frequency. Include comorbid conditions and contraindications, details on titration regimen or oncology staging when applicable, step-therapy exception information, and attach supporting clinical documentation if needed.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283843,1790206838,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":30,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":22},5909887256941,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","NOFR002 | 0522  \nTexas Standard Prior Authorization Request Form for Prescription Drug Benefits Please read all instructions below before completing this form.  \nPlease 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 patient’s or subscriber’s employer.  \nConsistent with TDI rule 28 TAC Section 19. 1820, health benefit plan issuers must accept the Texas Standard Prior Authorization Request Form for Prescription Drug Benefits if the plan requires prior authorization of a prescription drug or device.  \nIn addition to commercial issuers, the following public issuers must accept the form: Medicaid, the Medicaid managed care program, the Children’s 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.  \nIntended 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 issuer’s portal, to request prior authorization of a prescription drug benefit.  \nDo not use this form to: 1) request an appeal; 2) confirm eligibility; 3) verify coverage; 4) request a guarantee of payment; and 5) ask whether a prescription drug or device requires prior authorization; or 6) request prior authorization of a healthcare service.  \nAdditional Information and Instructions:  \nSection I – Submission:  \nEnter the name and contact information for the issuer or the issuer’s agent that manages or administers the issuer’s 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.  \nSection VI – Prescription Compound Drug Information:  \nList the quantities of ingredients in units of measure (mg, ml, etc.).  \nSection VIII – Patient Clinical Information:  \nEnter current ICD version.  \nSection IX – Justification:  \nIn the space provided or on a separate page:  \n• Provide pertinent clinical information to justify requests for initial or ongoing therapy, or increases in current dosage, strength, or frequency.  \n• Explain any comorbid conditions and contraindications for formulary drugs.  \n• Provide details regarding titration regimen or oncology staging, if applicable.  \n• Provide pertinent information about any step-therapy exception, if applicable. Read Texas Insurance Code Section 1369.0546(c) online.  \nAttach supporting clinical documentation (medical records, progress notes, lab reports, etc.), if needed.  \nNote: Some issuers may require more information or additional forms to process your request. If you think more  \ninformation or an additional form may be needed, please check the issuer’s website before faxing or mailing your request.  \nTexas Standard Prior Authorization Request Form for Prescription Drug Benefits Section I – Submission  \n\n| Submitted to:\u003Cbr>CVS Caremark | Phone: 1-800-294-5979 (non-specialty drugs)\u003Cbr>1-866-814-5506 (specialty drugs) | Fax: 1-888-836-0730 (non-specialty drugs) 1-866-249-6155 (specialty drugs) | Date: |\n| --- | --- | --- | --- |\n\nSection II – Review  \n\n| | Expedited/Urgent Review Requested: By checking this box and signing and dating below, I certify that applying the standard review time frame may seriously jeopardize the life or health of the patient or the patient’s ability to regain maximum function. |\n| --- | --- |\n| Signature of Prescriber or Prescriber’s Designee:  Date:  |  |\n\nSection III – Patient Information  \n\n| Name: |  | Phone: | DOB: |  |  | |  | Female Unknown |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Address: |  | City: |  |  | State: |  ","cbCaioJyODhGuj7i","https://ap.wps.com/l/cbCaioJyODhGuj7i","pdf",269706,"English","# Section I – Submission\n## Issuer contact information\n# Section II – Review\n## Expedited/urgent review certification\n# Section III – Patient Information\n## Member identifiers and demographics\n# Section IV – Prescriber Information\n## Provider identifiers and contact details\n# Section V – Prescription Drug Information\n## Requested drug details and therapy status\n# Section VI – Prescription Compound Drug Information\n## Ingredient listing\n# Section VII – Prescription Device Information\n## Device request details\n# Section VIII – Patient Clinical Information\n## ICD version\n# Section IX – Justification\n## Clinical justification and supporting documentation","[{\"question\":\"Who should receive and submit the Texas prior authorization request form?\",\"answer\":\"Submit the request to the issuer from whom authorization is being sought. Do not send it to the Texas Department of Insurance, the Texas Health and Human Services Commission, or the patient’s or subscriber’s employer.\"},{\"question\":\"What requests is the form intended to support?\",\"answer\":\"Use it to request authorization by fax or mail when prior authorization is required for a prescription drug or device, formulary exceptions, quantity limit overrides, or step-therapy requirement exceptions.\"},{\"question\":\"What information must be included for the clinical and justification sections?\",\"answer\":\"Provide pertinent clinical information to justify initial or ongoing therapy and any increases in dosage, strength, or frequency. Include comorbid conditions and contraindications, details on titration regimen or oncology staging when applicable, step-therapy exception information, and attach supporting clinical documentation if needed.\"}]","Texas Standard Prior Authorization Request Form for Prescription Drug Benefits - Application Instructions | PDF",1789620793]