Some forms cannot be viewed in a web browser and must be opened in Adobe Reader on your desktop system. Click here for instructions on accessing your form.

Effective Date: 
9/2021

Documents

Instructions

Updated: 4/2018

Purpose

For prescribing providers to request prior authorization for the Hepatitis C Virus agents.

When to Prepare

Detailed Instructions

  • Staff sends the form to the Medicaid-enrolled pharmacy, who then forwards the completed form by fax or mail.

Transmittal

  • Fax:

512-491-1962

  • Mail:

Vendor Drug Program (MC-2250)
Texas Health and Human Services
4900 North Lamar Blvd.
Austin, TX 78751

Questions

  • Direct questions about this form to the Vendor Drug Program at 800-435-4165.