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
- Orlistat (Xenical®) Approval (Medicaid) (PDF)
- Enzyme Statement of Medical Necessity (Medicaid) (PDF)
Instructions: All requests must include the diagnosis and ICD-9 code. Authorizations are good for one year.
- Palivizumab (Synagis®) Approval (Medicaid) (PDF)
- Pulmozyme/Tobramycin/Cayston/Kalydeco 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.
- Palivizumab (Synagis®) Approval (CSHCN) (PDF)
- 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.