Pharmacy Prior Authorization Forms

Electronic Prior Authorization Link

Providers are able to complete prior authorizations online via the following link:

Electronic Prior Authorization Information
Texas Standardized Prior Authorization Form for Prescription Drugs
Texas Medicaid-CHIP Prior Authorization Criteria Guide

Non-Preferred drugs require a Preferred Drug List (PDL) Prior Authorization (PA) review. The Preferred Drug List and the PDL Criteria Guide can be found here.

Formulary drugs (Formulary drug search here) may require a Clinical Prior Authorization. Please see the Clinical PA criteria that Molina has implemented below.

Clinical Prior Authorizations Implemented
 ADD/ADHD Agents Prior Authorization Form Addendum  
 Alinia Prior Authorization Form Addendum  
 Aliskiren Containing Agents  Prior Authorization Form Addendum  
 Allergen Extracts Prior Authorization Form Addendum  
 Amantadine ER Prior Authorization Form Addendum  
 Androgenic Agents Prior Authorization Form Addendum  
 Antiemetic Agents Prior Authorization Form Addendum  
 Antipsychotic Agents Prior Authorization Form Addendum  
 Anxiolytics and Sedative - Hypnotics Prior Authorization Form Addendum  
 Arikayce Prior Authorization Form Addendum  
 Binge Eating Disorder (BED) Agents Prior Authorization Form Addendum  
 Buprenorphine Agents Prior Authorization Form Addendum  
 Carisoprodol-Containing Agents Prior Authorization Form Addendum  
 CGRP Antagonists, Acute Prior Authorization Form Addendum  
 CGRP Antagonists, Chronic Prior Authorization Form Addendum  
 CNS Stimulants Prior Authorization Form Addendum  
 Colcrys Prior Authorization Form Addendum  
 Cough & Cold Agents Prior Authorization Form Addendum  
 Compounded Medications Prior Authorization Form Addendum  
 Contraceptives for CHIP Members Prior Authorization Form Addendum  
 COX-2 Inhibitors Prior Authorization Form Addendum  
 Cyclobenzaprine Prior Authorization Form Addendum  
 Cymbalta Prior Authorization Form Addendum  
 Cystic Fibrosis Agents Prior Authorization Form Addendum  
 Cytokine and CAM Antagonists Prior Authorization Form Addendum  
 Desmopressin Prior Authorization Form Addendum  
 Dextromethorphan Overutilization Prior Authorization Form Addendum  
 Diacomit Prior Authorization Form Addendum  
 Diabetic Supplies (Medicaid and CHIP) Prior Authorization Form Addendum  
 Diabetic Test Strips and Meters Prior Authorization Form Addendum  
 Diclofenac Prior Authorization Form Addendum
 Dopamine Agonists Prior Authorization Form Addendum
 Doxylamine/Pyridoxine Prior Authorization Form Addendum  
 DPP4 Inhibitors Prior Authorization Form Addendum  
 Dupixent Prior Authorization Form Addendum  
 Duplicate Therapy Prior Authorization Form Addendum  
 Emflaza Prior Authorization Form Addendum  
 Enzymes Prior Authorization Form Addendum  
 Epidiolex Prior Authorization Form Addendum  
 Early Refill Prior Authorization Form Addendum  
 Erythropoiesis-Stimulating Agents Prior Authorization Form Addendum  
 Evrysdi Prior Authorization Form Addendum  
 Fentanyl Agents Prior Authorization Form Addendum  
 Forteo Prior Authorization Form Addendum  
 Gabapentin Agents Prior Authorization Form Addendum  
 Gaucher's Disease Agents Prior Authorization Form Addendum  
 GI Motility Agents Prior Authorization Form Addendum  
 Glatiramer Acetate Injection Prior Authorization Form Addendum  
 GLP-1 Receptor Agonists Prior Authorization Form Addendum  
 Growth Hormone Agents Prior Authorization Form Addendum  
 HAE Agents Prior Authorization Form Addendum  
 Hemady Prior Authorization Form Addendum  
 Hepatitis C - Initial Request Form Prior Authorization Form Addendum  
 HP Acthar Prior Authorization Form Addendum  
 Hyperlipidemia Agents Prior Authorization Form Addendum  
 Imiquimod Prior Authorization Form Addendum  
 Increlex Prior Authorization Form Addendum  
 Inhaled Antibiotics Prior Authorization Form Addendum  
 Ketorolac Prior Authorization Form Addendum  
 Keveyis Prior Authorization Form Addendum  
 Leukotriene Modifiers Prior Authorization Form Addendum  
 Lidocaine Patches Prior Authorization Form Addendum  
 Lovaza Prior Authorization Form Addendum  
 Lyrica Prior Authorization Form Addendum  
 Makena Prior Authorization Form Addendum
 Monoclonal Antibodies for Asthma Prior Authorization Form Addendum
 Nuedexta Prior Authorization Form Addendum  
 Nuplazid Prior Authorization Form Addendum  
 Ophthalmic Immunomodulators Prior Authorization Form Addendum  
 Opiate/Benzodiazepine/Muscle Relaxant Combinations Prior Authorization Form Addendum  
 Opioid Policy Criteria (Formerly MME criteria) Prior Authorization Form Addendum  
 Oriahnn Prior Authorization Form Addendum  
 Orilissa Prior Authorization Form Addendum  
 Oxervate Prior Authorization Form Addendum
 Oxycontin / Narcotic Analgesic Prior Authorization Form Addendum  
 Palforzia Prior Authorization Form Addendum  
 PDE5-Inhibitors Prior Authorization Form Addendum  
 Phosphate Binders Prior Authorization Form Addendum  
 Promethazine Utilization Prior Authorization Form Addendum  
 Propylthiouracil Prior Authorization Form Addendum  
 Proton Pump Inhibitors Prior Authorization Form Addendum  
 Pulmonary Hypertension Agents Prior Authorization Form Addendum  
 Ranexa Prior Authorization Form Addendum  
 Retinoids Prior Authorization Form Addendum  
 Savella Prior Authorization Form Addendum  
 SGLT2 Agents Prior Authorization Form Addendum  
 Sickle Cell Agents Prior Authorization Form Addendum  
 Retrospective DUR Prior Authorization Form Addendum    
 Symlin Prior Authorization Form Addendum  
 Synagis Prior Authorization Form Addendum  
 Thiazolidinediones Prior Authorization Form Addendum  
 Topical Acne Agents Prior Authorization Form Addendum  
 Topical Immunomodulators Prior Authorization Form Addendum  
 Transthyretin Agents Prior Authorization Form Addendum  
 Urea Cycle Disorder Agents Prior Authorization Form Addendum  
 VMAT2 Inhibitors Prior Authorization Form Addendum  
 Wakix Prior Authorization Form Addendum  
 Vitamins/Minerals Prior Authorization Form Addendum  
 Xenical Prior Authorization Form Addendum  
 Xifaxan Prior Authorization Form Addendum  
 Xyrem/Xywav Prior Authorization Form Addendum  
 Zelboraf Prior Authorization Form Addendum  
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
 
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
 
   
   
   
   
   
   
   
   
   
           
     
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