Form 1356, Texas Medicaid Xyrem Prior Authorization Request

Instructions

Update: 8/2024

Purpose

Prescribing providers use this form to request pharmacy prior authorization for Xyrem (sodium oxybate). The prescriber or their staff faxes the form to the Medicaid-enrolled pharmacy, which faxes the form to the Texas Prior Authorization Call Center.

When to Prepare

• This form must accompany the Texas Department of Insurance Standard Prior Authorization Form (TDI Form NOFR002).
• Only use this form for people enrolled in Medicaid fee-for-service.
• Providers must complete all requested information or explain why the information is not available. The prescribing provider must sign and submit all requests.

Detailed Instructions

• Staff sends the form to the Medicaid-enrolled pharmacy, who then forwards the completed form by fax.

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).