Form 1347, Emflaza Standard Prior Authorization Addendum (Medicaid)

Instructions

Updated: 1/2023

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 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.

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).