Skip to main content

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

Need help? We're here for you.

Contact Us
On September 1, 2018, our premium payment services changed. These changes will make it easier for you to pay your premium. Read more. ×