Documents
Effective Date:
11/2022
- 1338.pdf (99.7 KB)
Instructions
Updated: 11/2022
Purpose
Prescribing providers use this form to request prior authorization for the cystic fibrosis agents Kalydeco, Orkambi and Symdeko.
When to Prepare
- This addendum must accompany the Texas Department of Insurance Standard Prior Authorization Form.
- Only use this form for people enrolled in Medicaid fee-for-service.
- The prescribing provider should sign and submit all requests. Complete all requested information or document why the information is not available.
Transmittal
Fax:
- 866-469-8590
Questions
- Direct questions about this form to the Texas Prior Authorization Call Center at 877-PA-TEXAS (877-728-3927).