Prescribing providers use this form to request prior authorization for cystic fibrosis agents.
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.
Direct questions about this form to the Texas Prior Authorization Call Center at 877-PA-TEXAS (877-728-3927).