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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
Hepatitis C - Refill Request Form Prior Authorization Form Addendum
Hepatitis C Addendum (Effective March 1, 2021) 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