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:

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