HHSC requires prior authorization for cystic fibrosis treatment agents for people enrolled in the Children with Special Health Care Needs (CSHCN) Services Program.
Prescribing providers complete and submit this and the Texas Standard Prior Authorization Request Form for Prescription Drug Benefits. Failure to submit both forms may cause delays or denial of authorization.
The provider must document why any information is unavailable and then submit the form annually, certifying the client requires these medications. Providers must supply medical necessity documentation for clients with a diagnosis other than cystic fibrosis.
Texas Health and Human Services
Children with Special Health Care Needs Services Program (MC-1938)
P.O. Box 149030
Austin, TX 78714-9347
Refer comments or questions about this form to the CSHCN Services Program at 800-252-8023.