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.

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), 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.

Obtaining Synagis® for Children with Special Health Care Needs (CSHCN) Clients:

  1. The treating provider identifies a CSHCN-enrolled client with indications for Respiratory Syncytial Virus (RSV) prophylaxis with Synagis®.
  2. The provider or provider's agent sends a prescription for Synagis® with supporting clinical information on the CSHCN Prior Authorization request form to a CSHCN-enrolled pharmacy. It is recommended that the pharmacy is a member of the Synagis® Distribution NetworkPlease do not submit multiple request forms.
  3. The start of the 2013-2014 respiratory syncytial virus (RSV) season varies based on a patient’s county of residence.
  4. The pharmacy faxes the completed CSHCN prior authorization request which includes the prescription at the bottom of the form to the CSHCN Services Program at: 512-776-7238. Prior authorization is required for all patients (pharmacies should include their telephone and fax number on the prescription form).
  5. For any questions related to prior authorization request forms pharmacies should call the Department of State Health Services (DSHS) Division of Family and Community Health Services toll free number at 1-800-252-8023 and select option 2.
  6. If the information submitted does not demonstrate medical necessity, the request is denied. Both the pharmacy and provider are notified of the denial.
  7. If the information submitted does demonstrate medical necessity, the request is approved and both pharmacy and provider are notified.
  8. If the prior authorization is approved, the dispensing pharmacy fills the prescription and ships an individual dose of the medication via overnight mail, in the name of the CSHCN client, directly to the provider. An initiation packet is mailed by the dispensing pharmacy to the client's family, informing them of Synagis® and its effects.
  9. The physician or provider under the direct supervision of the physician administers the Synagis® injection to the CSHCN client.
  10. The injection provider is allowed to bill for an injection administration fee and any medically-necessary office-based evaluation and management service provided at the time of injection. The pharmacy provider is reimbursed for the drug and dispensing fees.
  11. Before shipping and billing for a subsequent dose, the pharmacy must contact the injection provider to:
    • Obtain updated patient information (e.g. weight) to ensure the need and proper amount for the next dose.
    • Verify that the patient was administered all previously dispensed Synagis® prescriptions.
    • Pharmacies should maintain a log of the information obtained from the injecting provider.