Pharmacy prior authorization forms
Wellpoint follows the Texas Vendor Drug Program clinical criteria for pharmacy prior authorizations. The Clinical Prior Authorization Assistance Chart identifies which medications require prior authorization.
The forms listed should be used for pharmacy drugs requiring a prior authorization. Please submit completed forms and any required supplemental documentation to us via the contact information listed on the forms.
View the TX Vendor Drug Program site to determine additional prior authorization requirements:
Drugs requiring prior authorization:
Documents
A
- ADD-ADHD Agents
- Actemra
- Adbry
- Aldara
- Aldurazyme
- Alinia
- Altabax
- Amantadine Extended-Release Agents
- Amitiza
- Ampyra
- Amrix
- Androgenic Agents
- Antiemetic
- Antimigraine Agents, Ergot Derivatives
- Antimigraine Agents, Triptans
- Antipsychotics
- Anti-Seizure Agents
- Anxiolytics and Sedative Hypnotics
- Aranesp
- Arcalyst
- Arikayce
- Aubagio
B
C
- CNS Stimulants
- Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Prophylaxis
- Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Acute
- Carbaglu
- Carisoprodol, Generic
- Celebrex
- Cerdelga
- Cerezyme
- Cholestatic Pruritis Agents
- Cibinqo
- Cimzia
- Clopidogrel
- Colchicine Agents
- Copaxone
- Cosentyx
- Cough and Cold Medications
- Cyclobenzaprine
D
E
F
G
H
I
K
L
M
N
O
P
Q
R
S
T
V
W
X
Z
Provider tools & resources
- Log in to Availity
- Launch Provider Learning Hub
- Learn about Availity
- Precertification Lookup Tool
- Prior Authorization Requirements
- Claims Overview
- Member Eligibility & Pharmacy Overview
- Provider Manuals and Guides
- Referrals
- Forms
- Training Academy
- Pharmacy Information
- Electronic Data Interchange (EDI)