TX HHS Form 1354. PCSK9 Inhibitors Authorization Request (Medicaid Fee-for-Service)

The PCSK9 Inhibitors Authorization Request Form (TX HHS Form 1354) is a Medicaid Fee-for-Service form issued by the Texas Health and Human Services (HHS). The purpose of this form is to authorize the use of PCSK9 inhibitors, such as Praluent (Alirocumab) or Repatha (Evolocumab), for patients with familial hypercholesterolemia or atherosclerotic cardiovascular disease whose low-density lipoprotein cholesterol (LDL-C) levels are not adequately maintained with current treatments.

This form is intended for healthcare providers and pharmacists who need to request authorization for PCSK9 inhibitors as part of their patients' treatment plans. The form requires the submission of specific patient information, including diagnosis, treatment history, and LDL-C levels, in order to determine eligibility for PCSK9 inhibitor therapy. The issuing agency, Texas HHS, uses this form to ensure that PCSK9 inhibitors are used appropriately and safely for Medicaid beneficiaries.

The form also outlines the maintenance therapy approval criteria for Praluent (Alirocumab) or Repatha (Evolocumab), which includes maintaining concurrent use with maximally tolerated atorvastatin or rosuvastatin therapy, demonstrating a clinical response to PCSK9 inhibitor therapy, and meeting certain LDL-C level requirements. By completing this form, healthcare providers can request authorization for PCSK9 inhibitors and ensure that their patients receive the necessary treatment to manage their hyperlipidemia.