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

Instructions for Opening a Form

Some forms cannot be viewed in a web browser and must be opened in Adobe Acrobat Reader on your desktop system. Click here for instructions on opening this form.

Documents

Effective Date: 11/2022

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

Transmittal

Fax:

  • 866-469-8590

Questions