Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are FDA-approved for use with diet and adjunct treatment with maximally-tolerated statin therapy in adults with familial hypercholesterolemia or those with atherosclerotic cardiovascular disease (ASCVD) whose low-density lipoprotein cholesterol (LDL-C) is not adequately maintained with the current available treatments. The American Heart Association and American College of Cardiology recommends lifestyle modifications including a healthy diet and physical exercise to improve LDL-C levels. Approvals for PCSK9 inhibitors will be granted for a period of six months.
When to Prepare
Only use this form for people enrolled in Medicaid fee-for-service.
Prescribing providers should contact the appropriate managed care organization for prior authorization requirements for people enrolled in managed care.
The prescribing provider should sign and submit all requests. Complete all requested information or document why information is not available.
Fax: 866-617-8864Attention: Texas Prior Authorization Call Center
Direct questions about this form to the Texas Prior Authorization Call Center at 877-PA-TEXAS (877-728-3927).