CSHCN Services Program Prior Authorization
The following pharmacy prior authorization criteria are for individuals enrolled in the Children with Special Health Care Needs (CSHCN) Services Program.
CSHCN Clinical Prior Authorization
The following classes require prior authorization. Please request prior authorization as instructed below. All submissions must be from the prescribing provider.
- Cystic Fibrosis products
- Drugs include Cayston, Kalydeco, Pulmozyme, and Tobi
- CSHCN Cystic Fibrosis Treatment Products PA Form (PDF)
- Growth Hormone products
- HIV products and family planning and pulmonary hypertension drugs
- The prescribing physician must compose a letter of medical necessity (LMN) on office stationery. Pharmacy staff must submit the LMN by fax to the CSHCN Service Program.
- Please refer to appropriate RSV season information for prior authorization form and instructions.
CSHCN Standardized Prior Authorization Form
Prescribing providers may request prior authorization for the following drugs in the CSHCN Services Program using the Texas Standardized Prior Authorization Form (PDF).
- CSHCN Texas Standard PA Form for Growth Hormone Products (PDF)
- CSHCN Texas Standard PA Form for Synagis
Requests for these products require the submission of the standardized prior authorization form and the above addendums. Failure to submit the addendum with the request will result in prior authorization denial.
How to contact the Children with Special Health Care Needs (CSHCN) Services program:
- Physical and mailing address:
Texas Health and Human Services Commission
Children with Special Health Care Needs Services Program (MC-1938)
P.O. Box 149347
Austin, TX 78714-9347