Form 1355, PCSK9 Inhibitors Standard PA Addendum (Medicaid Fee-for-Service)

Instructions for Opening a Form

Some forms cannot be viewed in a web browser and must be opened in Adobe Acrobat Reader on your desktop system. Click here for instructions on opening this form.


Effective Date: 4/2020


Update: 4/2020


For prescribing providers to request pharmacy prior authorization (PA) for proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors.

When to Prepare

  • Only use this form for people enrolled in Medicaid fee-for-service.
  • The prescribing provider should sign and submit all requests. Please complete all requested information or document why information is not available.
  • This addendum must accompany the Texas Department of Insurance Standard Prior Authorization Form (TDI Form NOFR002 PDF).

Detailed Instructions

  • Provider staff sends the form to the Medicaid-enrolled pharmacy, who then forwards the completed form by fax.


  • Fax: 866-469-8590