Texas Prior Authorization Requests
The following prior authorization forms and instructions are for people enrolled in the Children with Special Health Care Needs (CSHCN) Services program. All submissions must be from the prescribing provider.
No form is required for HIV products, family planning drugs, and pulmonary hypertension drugs. The prescribing provider must compose a letter of medical necessity (LMN) on office stationery. Pharmacy staff must submit the LMN by fax to the CSHCN Service Program.
| Form Name | Form Number |
|---|---|
|
Cystic Fibrosis Treatment Products Authorization Request Drugs include Pulmozyme, Tobi, Cayston, and Kalydeco |
HHS 1143 |
| Growth Hormone Products Authorization Request | HHS 1312 |
| Synagis Authorization Request | HHS 1055 |
Texas Standard Prior Authorization Form Addendum
The following Standard Prior Authorization Form Addendum and instructions are for people enrolled in the Children with Special Health Care Needs (CSHCN) Services program. The Addendum must be accompanied by the Standard Prior Authorization Request (TDI Form NOFR002) (PDF). Failure to submit both forms will result in authorization denial. All submissions must be from the prescribing provider.
| Form Name | Form Number |
|---|---|
| Growth Hormone Agents Standard PA Addendum | HHS 1327 |
| Synagis Standard PA Addendum | HHS 1325 |