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
- This addendum must accompany the Texas Department of Insurance Standard Prior Authorization Form (TDI Form NOFR002) (PDF).
- 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).