CSHCN Prior Authorization Forms | Vendor Drug Program

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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 This addendum must be accompanied by the Standard Prior Authorization Request (TDI Form NOFR002) (PDF). Failure to submit both forms will result in authorization denial.	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)

Use either form. Refer to form for requirements and submission instructions.

Form Name	Form Number
Synagis Authorization Request	HHS 1055
Synagis Standard PA Addendum This addendum must be accompanied by the Standard Prior Authorization Request (TDI Form NOFR002) (PDF). Failure to submit both forms will result in authorization denial.	HHS 1325

Contacts

CSHCN Program Contacts