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 age two and older.
When to Prepare
- 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 should sign and submit all requests. Complete all requested information or document why information is not available.
- Fax: 866-469-8590
- Direct questions about this form to the Texas Prior Authorization Call Center at 877-PA-TEXAS (877-728-3927).