Downloading a Form to Your Computer
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- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
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Allows a physician to request a prior authorization for a refill of antiviral agents for Hepatitis C virus treatments.
- This form is only used for people enrolled in Medicaid fee-for-service.
- Prescribing providers should sign and fax the form to the Texas Prior Authorization Call Center. The provider should have completed Form 1335, Initial Prior Authorization Request – Medicaid Antiviral Agents for Hepatitis C Virus.
By fax: Texas Prior Authorization Call Center at 866-469-8590
Prescribing providers with questions should call the Texas Prior Authorization Call Center at 877-728-3927.