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: 2/2023

Instructions

Updated: 1/2023

Purpose

Prescribing providers use this form to request prior authorization for cystic fibrosis agents.

When to Prepare

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).