Form 1338, Cystic Fibrosis Treatment Agents (Kalydeco/Orkambi/Symdeko) Prior Authorization Request

Instructions

Updated: 7/2024

Purpose

Prescribing providers use this form to request prior authorization for cystic fibrosis treatment agents.

When to Prepare

• This addendum must accompany the Texas Department of Insurance Standard Prior Authorization Form.
• Only use this form for people enrolled in Medicaid fee-for-service.
• The prescribing provider must sign and submit all requests. Complete all requested information or explain why the information is not available.

Transmittal

Fax: 866-469-8590

Questions

Direct questions about this form to the Texas Prior Authorization Call Center at 877-728-3927 (877-PA-TEXAS).