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Preauthorization and notification forms

The documents below list services and medications that require preauthorization for patients with Medicaid, Medicare Advantage, dual Medicare-Medicaid and commercial coverage.

Medicare Commercial Medicaid State-specific preauthorization statistics

Commercial preauthorization list summary of changes

Current preauthorization and notification lists

Upcoming preauthorization and notification lists (effective July 1, 2023)

Previous preauthorization and notification lists

Preauthorization resources

Use the links below to submit the preauthorization form, find other forms or learn more about the process.

Ready to submit

Coverage criteria

Fax forms

Download a form to submit your preauthorization by fax.

Standard form, PDF

Texas form, PDF

New Mexico form, PDF

Indiana form, PDF

Arizona form, PDF

Texas exemptions

This law applies to licensed Texas physicians/providers providing healthcare services to commercial, fully-insured members. The law is not applicable to Self-funded plans (Level Funded Premium (LFP) or Administrative Services Only (ASO)), Medicare, Medicaid or TriCare.

Texas House Bill 3459 – Preauthorization Exemptions, PDF