Downloading a Form to Your Computer

Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.

  1. Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
  2. Select the folder you want to save the file in and then click "Save."
  3. 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.

    Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.

    If still having trouble viewing or downloading a form, click here.

Effective Date: 




Updated: 3/18



To reduce the risk of preterm birth with singleton pregnancy and a history of spontaneous singleton preterm birth. Makena is a once weekly treatment administered by a healthcare provider.

When to Prepare

  • Only use this form for people enrolled in Medicaid fee-for-service.
  • Prescribing providers should contact the appropriate managed care organization for prior authorization requirements for people enrolled in managed care.
  • The prescribing provider should sign and submit all requests. Please complete all requested information or document why information is not available.


Detailed Instructions

Makena requests may be submitted for approval just prior to 16 weeks, 0 days gestation to allow time for the prior authorization approval process and shipping from the pharmacy.


  • Fax: 866-617-8864
    • Attention: Texas Prior Authorization Call Center