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.
List of Forms
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.
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), Cayston, and Kalydeco (CSHCN program)
Instructions: A separate form is required for each Pulmozyme, Tobramycin, Cayston or Kalydeco request. An approved prescribing physician must complete and sign this form annually certifying that the client continues to require these medications. Pulmozyme and Kalydeco are covered for the treatment of cystic fibrosis as prescribed by a program-approved pulmonologist and may be initially prior authorized for a six-month period with a subsequent prior authorization 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.
Enzyme Statement of Medical Necessity (Medicaid)
Instructions: All requests must include the diagnosis and ICD-9 code. Authorizations are good for one year.