Cystic Fibrosis Treatment Products
- Drugs include Pulmozyme, Tobi, Cayston, and Kalydeco. Refer to form for requirements and submission instructions.
| Form Name | Form Number |
|---|---|
| Cystic Fibrosis Treatment Products Authorization Request | HHS 1143 |
Family Planning Drugs
- A letter of medical necessity must be sent on office stationary and faxed to the CSHCN Service Program.
Growth Hormone Agents
- Use either form. Refer to form for requirements and submission instructions.
| Form Name | Form Number |
|---|---|
| Growth Hormone Products Authorization Request | HHS 1312 |
Growth Hormone Agents Standard PA Addendum
|
HHS 1327 |
HIV Products
- A letter of medical necessity must be sent on office stationary and faxed to the CSHCN Service Program.
Pulmonary Hypertension Drugs
- A letter of medical necessity must be sent on office stationary and faxed to the CSHCN Service Program.
Synagis (palivizumab)
- Refer to the form for Synagis prior authorization requirements and submission instructions.