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 physician.

Cystic Fibrosis Treatment Products

Drugs include Pulmozyme, Tobi, Cayston, and Kalydeco.

  1. CSHCN Authorization Request Cystic Fibrosis Treatment Products (HHS Form 1143)

Growth Hormone products

Please use either form #1 or #2.

  1. CSHCN Authorization Request Growth Hormone Products (HHS Form 1312)
  2. CSHCN Authorization Request Growth Hormone Products Addendum (HHS Form 1327)

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.

Synagis

Please use either form #1 or #2.

  1. CSHCN Services Program Sysnagis Authorization Request (HHS Form 1055)
  2. CSHCN Services Program Sysnagis Authorization Request Addendum (HHS Form 1325)