Form 1347, Emflaza Prior Authorization Request

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Documents

Effective Date: 7/2024

Instructions

Updated: 7/2024

Purpose

Prescribing providers use this form to request pharmacy prior authorization for Emflaza (deflazacort). Deflazacort is FDA-approved for the treatment of Duchenne muscular dystrophy (DMD) in patients two and older.

When to Prepare

  • This form must accompany the Texas Standard Prior Authorization Request Form for Prescription Drug Benefits.
  • 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 explain why the information is not available.

Transmittal

  • Fax: 866-469-8590

Questions

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