Form 1404, Mosquito Repellent Standing Order Prescription Template

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Effective Date
1404.pdf (195.75 KB)



Updated: 5/2021



Texas Health and Human Services issued the Texas Medicaid Standing Order for Mosquito Repellent for use by people enrolled in Medicaid, Children’s Health Insurance Program and Healthy Texas Women Program. The order serves as a prescription and allows pharmacists to dispense mosquito repellent under the terms of the order. Pharmacies are encouraged to use this order instead of contacting the health care provider for an individual prescription for mosquito repellent. Texas HHS requires a prescription from a valid health care provider for any pharmacy or pharmacist not operating under the standing order.

Detailed Instructions

Request a copy of the Texas Medicaid Standing Order for Mosquito Repellent by emailing the Vendor Drug Program at The pharmacy staff retains HHS Form 1404 in their records.


Refer comments or questions about this form to the Vendor Drug Program at