TX HHS Form 1347. Emflaza Prior Authorization Request

The Texas Health and Human Services (HHS) has issued Form 1347, Emflaza Prior Authorization Request, to facilitate the treatment of Duchenne muscular dystrophy in patients aged 2 years and older. This form serves as a crucial tool for healthcare providers to request prior authorization for Emflaza (deflazacort), a medication approved for treating this condition.

This form is designed for patients enrolled in Medicaid fee-for-service, and its completion is essential for prior authorization renewal requests. The form must be faxed 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 this addendum may result in delays and denial of prior authorization, impacting patient care.

The Emflaza Prior Authorization Request form outlines specific approval criteria for patients with Duchenne muscular dystrophy, including a diagnosis, unsuccessful treatment with prednisone, and the presence of certain adverse events. The form also details denial criteria, such as age less than 2 years, non-FDA approved indications, and recent use of CYP3A4. Healthcare providers must carefully review these criteria to ensure accurate completion of the form.