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Effective Date: 




Updated: 2/2020



To request prior authorization for patients enrolled in the Children with Special Health Care Needs (CSHCN) Services Program. The prescribing provider or provider assistant sends a prescription for the requested medication with refills and supporting information to the CSHCN-enrolled pharmacy. The pharmacy must be participating in the CSHCN program (see (link is external)).

Pulmozyme and Kalydeco are covered for the treatment of cystic fibrosis as prescribed by a program-approved pulmonologist and may be initially prior authorized for a six-month period with a subsequent prior authorization for one year, but only one month’s supply may be dispensed at a time. Tobramycin and Cayston are covered for the treatment of cystic fibrosis as prescribed by a program-approved pulmonologist, and are limited to an administration cycle of 28 days of treatment followed by 28 days with no Tobramycin/Cayston treatment.



When to Prepare or Update

This form is only used for people enrolled in the CSHCN Services Program.

A program-approved prescribing physician must complete and sign this form annually certifying that the patient continues to require these medications. The physician may supply additional information if needed.

Requests must be signed and submitted by the prescribing physician. Please complete all requested information or document why information is not available.






Texas Health and Human Services


Children with Special Health Care Needs Services Program (MC-1938)


P.O. Box 149347


Austin, TX 78714-9347


Detailed Instructions

  1. If a patient is enrolled in a CSHCN service program an approved prescribing physician will complete this form.
  2. The prescribing physician must supply medical necessity documentation for patients with a diagnosis other than cystic fibrosis.
  3. The prescribing physician must sign and submit the form completing all applicable fields.
  4. If information in not available, the prescribing physician must document why the information is not available. 
  5. Direct all questions about this form to the CSHCN Services Program at 800-252-8023.