Form 1338, Cystic Fibrosis Treatment Agents (Kalydeco/Orkambi/Symdeko) Prior Authorization Request

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Effective Date: 7/2024

Updated: 7/2024

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

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 must sign and submit all requests. Complete all requested information or explain why the information is not available.

Fax: 866-469-8590

Questions

Direct questions about this form to the Texas Prior Authorization Call Center at 877-728-3927 (877-PA-TEXAS).