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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:

Fax Number 


P.O. Box 31397

Tampa, FL 33631


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 





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

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Welcome Prescription Drug Plan members! We have important information to share with you about your 2019 plan. Read More. ×