TX HHS Form 1338. Cystic Fibrosis Treatment Agents (Kalydeco/Orkambi/Symdeko) Prior Authorization Request

The TX HHS Form 1338 is a prior authorization request form for Cystic Fibrosis Treatment Agents (Kalydeco/Orkambi/Symdeko) used by healthcare providers to initiate treatment for patients enrolled in Medicaid fee-for-service. The form is essential for processing the prior authorization and ensuring timely patient care.

This form is issued by Texas Health and Human Services (HHS) and is designed for use by prescribers, including physicians and other authorized healthcare professionals. The form requires completion of three sections: Patient Information, Prescriber Information, and Medication Information. Additionally, the form asks specific questions about the patient's gene mutation to ensure accurate treatment.

The form must be completed in its entirety and submitted along with the Texas Standard Prior Authorization Request Form for Prescription Drug Benefits (TDI Form NOFROO2) to the Texas Prior Authorization Call Center at 866-469-8590. Incomplete forms or failure to submit both forms may result in delays, prior authorization denial, or both.