Form Nofr002 - Texas Standard Prior Authorization Request Form For Prescription Drug Benefits

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Texas Standard Prior Authorization
Request Form for Prescription Drug Benefits
NOFR002 | 0615
Texas Department of Insurance
Please read all instructions below before completing this form.
Please 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.
Beginning September 1, 2015, health benefit plan issuers must accept the Texas Standardized Prior Authorization Request
Form for Prescription Drug Benefits if the plan requires prior authorization of a prescription drug or device.
In 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.
Intended 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.
Do not use this form to: 1) request an appeal; 2) confirm eligibility; 3) verify coverage; 4) request a guarantee of payment;
5) ask whether a prescription drug or device requires prior authorization; or 6) request prior authorization of a health care
service.
Additional Information and Instructions:
Section I – Submission:
Enter 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.
Section VI – Prescription Compound Drug Information:
List the quantities of ingredients in units of measure (mg, ml, etc.).
Section VIII – Patient Clinical Information:
Enter ICD Version 9 or 10, as applicable.
Section IX — Justification:
In the space provided or on a separate page:
• Provide pertinent clinical information to justify requests for initial or ongoing therapy, or increases in current
dosage, strength, or frequency.
• Explain any comorbid conditions and contraindications for formulary drugs.
• Provide details regarding titration regimen or oncology staging, if applicable.
• Provide pertinent information about any step-therapy exception, if applicable.
Attach supporting clinical documentation (medical records, progress notes, lab reports, etc.), if needed.
Note: Some issuers may require more information or additional forms to process your request. If you think more information or an
additional form may be needed, please check the issuer’s website before faxing or mailing your request.
Texas Department of Insurance | 333 Guadalupe | Austin, Texas 78701 | (800) 578-4677 | | @TexasTDI

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