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

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).