Prior Authorization Request Forms
The following prior authorization forms are for people enrolled in the Children with Special Health Care Needs (CSHCN) Services program. All submissions must be from the prescribing physician.
- Cystic Fibrosis Treatment Products
- Drugs include Pulmozyme, Tobi, Cayston, Kalydeco,
- CSHCN Clinical Prior Authorization Request Form (PDF)
- Growth Hormone products
- HIV products, family planning, and pulmonary hypertension drugs
- The prescribing physician must compose a letter of medical necessity (LMN) on office stationery. Pharmacy staff must submit the LMN by fax to the CSHCN Service Program.
- Please refer to appropriate RSV season information for prior authorization form and instructions.
Texas Standard Prior Authorization Forms
Prescribing providers may request prior authorization for the following drugs in the CSHCN Services Program using the Texas Standard Prior Authorization Form (PDF).
- Texas Standard PA Form for Growth Hormone Products (PDF)
- Texas Standard PA Form for Synagis
Requests for these products require the submission of the standard prior authorization form and the above addendums. Failure to submit the addendum with the request will result in authorization denial.