CSHCN Services Program Prior Authorization

The CSHCN Services Program requires prior authorization for the following drugs:

  • Cystic Fibrosis products (includes Cayston, Kalydeco, Pulmozyme, and Tobi)
  • Growth Hormone products
  • Synagis

Refer to the CSHCN Services Program Prior Authorization Requests for prior authorization request forms and addendums.

Prescribing providers must send a letter of medical necessity on office stationery to the CSHCN Service Program for the following drugs:

  • Family planning products
  • Human Immunodeficiency Virus (HIV) drugs
  • Pulmonary hypertension drugs

Contact the CSHCN Services Program for prior authorization questions.

The program may cover HIV drugs when prior authorized for the treatment of HIV/AIDS, while the person completes the Texas HIV Medication Program eligibility process. Covered HIV medications are subject to change. People have up to 60 days of prior approval while waiting for acceptance or denial from the Texas HIV Program.

After the 60 days prior approval period, the person must contact the Texas HIV Program to obtain these medications. Claims for these drugs will reject with NCPDP code 75 ("Prior Authorization Required") and include the message “Call HIV Program 1-800-255-1090” in the “Additional Message Information” field (526FQ), except when the person is not eligible for the drug from the HIV Program. In these cases, the CSHCN Services Program should be notified and the claim will process for payment under CSHCN.

The Texas Department of Insurance requires HHSC to publish the Texas Standardized Prior Authorization Request Form for Health Care Services (TDI Form NOFR002) for prescribing providers as of September 1, 2015. Refer to TAC Section 19.1820 (Subchapter S: Prior Authorization Request Form for Prescription Drug Benefits, Required Acceptance, and Use).

Providers use this form to request prior authorization by fax or mail. Some medications will require providers to submit an addendum form to capture additional information. Failure to submit both the Standardized Prior Authorization Request and addendum may result in an authorization denial.