Prior Approval request forms

Prior approval requests are to be submitted by the prescribing physician.  Please complete all entries, or document why information is not available.  Incomplete forms will be returned with no action taken.  Please date and sign the form and then fax to Vendor Drug DUR at 512-491-1962.

Growth Hormone Approval (CSHCN program)
Instructions: growth hormones are covered for the treatment of clients with specific diagnoses involving growth hormone deficiency.  If an initial or extension request cannot be approved based on the above criteria, the approval request may be sent for medical review and reconsideration to the CSHCN Services Program.

Human Growth Hormone Injections for Children (CHIP Program)
Instructions: children diagnosed with growth failure due to a lack of adequate endogenous growth hormone secretion may be approved for therapy upon physician documentation of medical necessity.  Approval may be granted for a period of up to 12 months. If an extension of benefits is needed the physician must submit a progress report indicating growth and maturation. This must include the date the patient was last seen, the patient’s height and weight at that time and a growth chart documenting growth over, at a minimum, the previous three years (see form for full instructions).

Orlistat (Xenical®)
Instructions: Texas Medicaid covers Xenical® therapy for the treatment of hyperlipidemia only.  Xenical® will not be approved for concurrent use with other cholesterol lowering agents. Prior approval requests must include a recent lipid profile.  The initial approval period will be for a period of six months. Recipients age 21 or greater diagnosed with hyperlipidemia may be approved for treatment with Xenical® upon physician documentation of medical necessity. An extension of benefits may be granted upon physician documentation of therapy successes (see form for full instructions). 

Pulmozyme, Tobramycin (Tobi), and Cayston (CSHCN program)
Instructions:  A separate form is required for each Pulmozyme, Tobramycin, or Cayston request.  An approved prescribing physician must complete and sign this form annually certifying that the client continues to require these medications.  Pulmozyme is covered for the treatment of cystic fibrosis as prescribed by a program-approved pulmonologist, and may be initially authorized for a six-month period, with subsequent authorizations for one year, but only one month’s supply may be dispensed at a time.  Tobi and Cayston are covered for the treatment of cystic fibrosis as prescribed by a program-approved pulmonologist, and are limited to an administration cycle of 28 days of treatment followed by 28 days with no Tobi/Cayston treatment.