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Who May Make a Request

Your prescriber may ask us for a coverage determination on your behalf.  If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative.  Contact us to learn how to name a representative.

This form may be sent to us by mail or fax:

Address
Fax Number 

TexanPlus

P.O. Box 31397

Tampa, FL 33631

1-855-714-6218

Expedited appeal requests can be made by phone at:

Health Plan
Phone Number 

TexanPlus HMO (Houston/ Beaumont)

TexanPlus HMO (Dallas/ Ft. Worth)

TexanPlus HMO-POS

TexanPlus HMO-SNP 

1-866-230-2513

1-800-958-2707

1-866-230-2513

1-844-879-4367

Enrollee's Information ?

Enrollee's Contact Information

Requestor's Contact Information ?

Prescription Drug Requested

Type of Coverage Determination Request

Supporting Information for an Exception Request or Prior Authorization ?

Prescriber's Information

Diagnosis and Medical Information

Rationale for Request

Print Form
contact-us

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