Effective Date: 10/2022
Prescribing providers use this form to request pharmacy prior authorization for Xyrem® (sodium oxybate).
When to Prepare
- Only use this form for people enrolled in Medicaid fee-for-service.
- Providers should complete all requested information or document why the information is not available. The prescribing provider should sign and submit all requests.
- This addendum must accompany the Texas Department of Insurance Standard Prior Authorization Form (TDI Form NOFR002).
- Staff sends the form to the Medicaid-enrolled pharmacy, who then forwards the completed form by fax.
- Fax: 866-469-8590
- Providers should direct questions about this form to the Texas Prior Authorization Call Center at 877-PA-TEXAS (877-728-3927).