TX HHS Form 1355. PCSK9 Inhibitors Standard PA Addendum (Medicaid Fee-for-Service)

The PCSK9 Inhibitors Standard PA Addendum (Medicaid Fee-for-Service) is a form designed to facilitate prior authorization for patients enrolled in Medicaid fee-for-service. This addendum helps streamline the process of obtaining approval for PCSK9 inhibitors, ensuring timely patient care and treatment.

This form requires prescribers or their designees to provide specific information about the patient's medical history, including previous treatments and LDL-C levels. The form also asks about the patient's current therapy and whether they have tried 90 days of atorvastatin, rosuvastatin, or ezetimibe treatment. Additionally, prescribers must indicate whether the patient has a low-density lipoprotein cholesterol (LDL-C) level greater than 70mg/dl despite treatment with these medications.

To complete this form, prescribers should fax both the Texas Standard Prior Authorization Request Form for Prescription Drug Benefits (TDI Form PDF) and Form 1355 to the Texas Prior Authorization Call Center at 866-469-8590. Incomplete forms or failure to submit this addendum may cause delays in patient care and prior authorization denial or both.

• This form is only for patients enrolled in Medicaid fee-for-service.
• Prior authorization is required for PCSK9 inhibitors treatment.
• The form requires prescribers to provide specific information about the patient's medical history and current therapy.