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For prescribing providers to request prior authorization for the cystic fibrosis agents Kalydeco, Orkambi and Symdeko.
When to Prepare
- Only use this form for people enrolled in Medicaid fee-for-service.
- The prescribing provider should sign and submit all requests. Please complete all requested information or document why information is not available.
- This addendum must accompany the Texas Department of Insurance Standard Prior Authorization Form (TDI Form NOFR002) (PDF).
- Staff sends the form to the Medicaid-enrolled pharmacy, who then forwards the completed form by fax or mail.
Vendor Drug Program (MC-2250)
Texas Health and Human Services
4900 North Lamar Blvd.
Austin, TX 78751
- Direct questions about this form to the Vendor Drug Program at 800-435-4165.