Form 1354, PCSK9 Inhibitors Authorization Request (Medicaid Fee-for-Service)

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Effective Date: 4/2020


Update: 4/2020


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.
    Detailed Instructions


  • Fax: 866-617-8864
    • Attention: Texas Prior Authorization Call Center