Form 1338, Cystic Fibrosis Agents (Kalydeco/Orkambi/Symdeko) – Medicaid Standard PA Addendum

Instructions

Updated: 11/2019

Purpose

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).

Detailed Instructions

• Staff sends the form to the Medicaid-enrolled pharmacy, who then forwards the completed form by fax or mail.

Transmittal

• Fax:

512-491-1962

• Mail:

Vendor Drug Program (MC-2250)
Texas Health and Human Services
4900 North Lamar Blvd.
Austin, TX 78751

Questions

• Direct questions about this form to the Vendor Drug Program at 800-435-4165.