For prescribing providers to request pharmacy prior authorization for Oxycontin® (oxycodone ER).
When to Prepare
- Only use this form for people enrolled in Medicaid fee-for-service.
- The prescribing provider should sign and submit all requests. Please complete all requested information or document why information is not available.
- This addendum must accompany the Texas Department of Insurance Standard Prior Authorization Form (TDI Form NOFR002) (PDF).
- Staff sends the form to the Medicaid-enrolled pharmacy, who then forwards the completed form by fax.
- Fax: 866-469-8590
- Direct questions about this form to the Texas Prior Authorization Call Center at 877-PA-TEXAS (877-728-3927).