Form 1347, Emflaza Standard Prior Authorization Addendum (Medicaid)

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Effective Date
1347.pdf (118.1 KB)


Updated: 8/2021


For prescribing providers to request pharmacy prior authorization for Emflaza (deflazacort). Deflazacort is FDA-approved for the treatment of Duchenne muscular dystrophy (DMD) in patients two years of age and older.

Treatment approval criteria for Emflaza (deflazacort) includes:

  • Patient two years of age and older with a diagnosis DMD.
  • Patient has tried prednisone for three months or longer and has one the following adverse events as a result prednisone use:
    • Cushingoid appearance;
    • Central (truncal) obesity;
    • Undesirable weight gain (greater than or equal to 10% body weight gain over a six-month period);
    • Diabetes and/or hypertension that is difficult to manage; or
    • Experienced a severe behavioral adverse event.
  • For renewal requests:
    • Complete Sections 1, 5 and 6 of this form.

Reasons for denial include but are not limited to the following:

  • Age less than two years.
  • Use of CYP3A4 in last 90 days.
  • No previous trial with prednisone.

When to Prepare


  • Fax: 866-469-8590