Prior Authorization Forms
Prior authorization forms are completed and submitted by the prescribing physician to the Vendor Drug Program.
Fee-For-Service Medicaid Criteria
- Xenical® (orlistat) Approval (Medicaid) (PDF)
- Enzyme Statement of Medical Necessity (Medicaid) (PDF)
- Synagis® (palivizumab) Approval (Medicaid) (PDF)
- Pulmozyme/Tobramycin/Cayston/Kalydeco Approval (CSHCN) (PDF)
NB: This form covers the following four drugs:
- Cayston® (aztreonam for inhalation solution)
- Kalydeco® (ivacaftor)
- Pulmozyme® (dornase alfa)
- Tobi® (tobramycin inhalation powder)
- Synagis® (palivizumab) Approval (CSHCN) (PDF)
- Growth Hormone Approval (CSHCN) (PDF)
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.
- Family Planning / HIV Products / Pulmonary hypertension drugs (CSHCN)
Pharmacy staff should obtain a letter of medical necessity from the prescribing physician on office stationery and fax to the CSHCN Services Program at 512-776-7162. For more information call CSHCN at 1-800-252-8023.