The Texas Pre Authorization Request form is a critical document used to obtain approval for certain medications under Texas Medicaid. This form ensures that patients receive necessary medications while complying with state regulations. Proper completion and submission of this form can expedite the approval process for Global Prescription Exceptions.
The Texas Pre Authorization Request form plays a crucial role in the Medicaid process, particularly for Global Prescription Exceptions. This form is designed to ensure that patients receive the necessary medications while adhering to the guidelines set by Medicaid. It requires detailed information about the patient, including their name, ID, date of birth, and the prescribing physician's details. Additionally, it asks for the drug name and diagnosis, which helps in assessing the medical necessity of the requested treatment. The form includes a series of questions that must be answered, which determine if the drug is being used for an FDA-approved indication and whether the patient has tried other preferred alternatives. It also verifies that the prescribed medication aligns with the manufacturer’s dosing guidelines. Once completed, the form must be signed and dated before being faxed to Caremark at a secure number, ensuring compliance with HIPAA regulations. If there are any questions during the process, Caremark is available to assist. By following this structured approach, the Texas Pre Authorization Request form helps streamline the approval process for necessary medications, ultimately supporting better health outcomes for patients.
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?
2.
Is the requested drug being used for an FDA‐approved indication?
[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
accepted guidelines, etc.)?
4. Has the patient demonstrated a failure of or intolerance to a majority (not more than three)
of the preferred formulary or preferred drug list alternatives for the given diagnosis?
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.,
package insert, AHFS, Micromedex, current accepted guidelines, etc.)?
6. Is the drug being prescribed for a medically accepted indication that is recognized as a
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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