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

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Effective Date
11/2019
Document
1338.pdf (112.23 KB)

Instructions

Updated: 11/2019

 

Purpose

For prescribing providers to request prior authorization for the cystic fibrosis agents Kalydeco, Orkambi and Symdeko.

 

When to Prepare

 

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.