Pharmacy prior authorization forms
Amerigroup 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 a prior authorization:
Documents
A
B
C
- CNS Stimulants
- Calcitonin
- Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonist, Chronic
- Calcitonin Gene-Related Peptide Receptor (CGRP) Antagonists, Acute
- Carbaglu
- Carisoprodol, Generic
- Celebrex
- Cerdelga
- Cerezyme
- 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 Now
- 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)