Form 1347 "Emflaza Authorization Request (Medicaid)" - Texas

What Is Form 1347?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 1347 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form 1347 "Emflaza Authorization Request (Medicaid)" - Texas

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Form 1347
November 2020-E
Texas Vendor Drug Program
Emflaza Authorization Request (Medicaid)
This form contains information about prior authorization criteria for Emflaza (deflazacort). The drug FDA-approved for the treatment of
Duchenne muscular dystrophy in patients 2 years and older. This form is only for people enrolled in Medicaid fee-for-service. Using this form
for people in Medicaid managed care or other programs may lead to unnecessary delays in access to treatment.
Medicaid managed care reminder: refer to the
MCO Assistance Chart
for each MCO’s prior authorization contact information and
requirements.
Approval Criteria
2 years or older with a diagnosis of Duchenne muscular dystrophy
Therapy prescribed by, or in consultation with, a neurologist
Tried prednisone for six months or longer and has one of the following adverse events because of prednisone use:
o
Cushingoid appearance
o
Central (truncal) obesity
o
Undesirable weight gain (greater than or equal to 10% body weight gain over six months)
o
Diabetes or hypertension difficult to manage
o
Experienced a severe behavioral adverse event
For renewal requests
o
Complete sections 1, 5 and 6
Denial Criteria
Reasons for denial include, but are not limited to:
Age less than 2 years
Not prescribed by or in consultation with a neurologist
Non-FDA approved indications
No previous trial with prednisone
Form 1347
November 2020-E
Texas Vendor Drug Program
Emflaza Authorization Request (Medicaid)
This form contains information about prior authorization criteria for Emflaza (deflazacort). The drug FDA-approved for the treatment of
Duchenne muscular dystrophy in patients 2 years and older. This form is only for people enrolled in Medicaid fee-for-service. Using this form
for people in Medicaid managed care or other programs may lead to unnecessary delays in access to treatment.
Medicaid managed care reminder: refer to the
MCO Assistance Chart
for each MCO’s prior authorization contact information and
requirements.
Approval Criteria
2 years or older with a diagnosis of Duchenne muscular dystrophy
Therapy prescribed by, or in consultation with, a neurologist
Tried prednisone for six months or longer and has one of the following adverse events because of prednisone use:
o
Cushingoid appearance
o
Central (truncal) obesity
o
Undesirable weight gain (greater than or equal to 10% body weight gain over six months)
o
Diabetes or hypertension difficult to manage
o
Experienced a severe behavioral adverse event
For renewal requests
o
Complete sections 1, 5 and 6
Denial Criteria
Reasons for denial include, but are not limited to:
Age less than 2 years
Not prescribed by or in consultation with a neurologist
Non-FDA approved indications
No previous trial with prednisone
Form 1347
Page 2 / 11-2020-E
Section I – Patient Information
Patient Name (First, Last, MI)
Medicaid ID No.
Date of Birth (MM/DD/YY)
Drug Allergies
Section II – Patient History
Required Diagnosis (please check one of the following):
ICD-9: 359.1 Hereditary Progressive Muscular Dystrophy
Date of Diagnosis
ICD-10: G71.0 Muscular Dystrophy
Section III – Drug Treatment History (If renewal request, please skip to Section V)
Drug
Last Prescribed Dose
Start Date
End Date
Prednisone
Other (list drug name(s) below)
Section IV – Treatment Information (If renewal request, please skip to Section V)
Prescribed by, or in consultation with, a neurologist?
Yes
No
Name of Specialist:
Date of Consult:
Patient has tried prednisone for greater than or equal to (≥) six months?
Yes
No
Patient has had one of the following adverse events because of prednisone therapy:
Date of Diagnosis
Cushingoid appearance
Central (truncal) obesity
Undesirable weight gain (greater than or equal to [≥] 10 % of body weight gain six-months)
Diabetes or hypertension that is difficult to manage
Experienced a severe behavioral adverse event
Section V – Renewal Information
Patient continues to have a positive response to Emflaza therapy:
Yes
No
Section VI – Prescriber Information and Signature
Prescriber Name
Prescriber NPI
Address (Street, City, State and ZIP Code)
Prescriber License
Specialty (if applicable)
Office Area Code and Phone No.
Preparer Name (if other than prescriber)
Office Area Code and Fax No.
Prescriber Signature
Date
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