Form 1353, OxyContin Standard PA Addendum (Medicaid)

Instructions

Update: 5/2018

Purpose

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).

Detailed Instructions

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

Transmittal

• Fax: 866-469-8590

Questions

• Direct questions about this form to the Texas Prior Authorization Call Center at 877-PA-TEXAS (877-728-3927).