Texas Standard Prior Authorization Form - PCSK9 Inhibitors - PA Form

Sep 17, 2026

Texas Standard Prior Authorization Form for PCSK9 inhibitors collects required member, clinical, and prescribing details to support prior authorization decisions for Superior HealthPlan. The form captures patient information, diagnosis selection, treatment history with statins and related agents, and PCSK9 treatment status (initial or continuation). It also requires LDL-C laboratory values and timing rules, including renewal thresholds based on baseline reductions. Prescriber information, signature, and NPI licensing details complete submission by fax to Envolve Pharmacy Solutions.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Section 1 - Patient Information

Section 2 - Patient History

Section 3 - PCSK9 Inhibitor Prescription Information

Section 4 - Laboratory Information

Section 5 - Prescriber Information and Signature

Texas Standard Prior Authorization Form-PCSK9 Inhibitors Please complete and fax all required documents to Envolve Pharmacy Solutions at 1-833-423-2523 for prior authorization requests for Superior HealthPlan members. Superior follows the Texas Vendor Drug Program clinical prior authorization criteria for PCSK9 inhibitors. Section 1-Patient Information | First Name | | Last Name | | MI | | --- | --- | --- | --- | --- | | DOB | Cardholder ID | | Applicable drug allergies | | Section 2-Patient History | Required Diagnosis (please check one of the following): | | | | | | --- | --- | --- | --- | --- | | Diagnosis of Heterozygous Familial Hypercholesteremia | | | Date of diagnosis: | | | Clinical Atherosclerotic Cardiovascular Disease | | | Date of diagnosis: | | | Diagnosis of Homozygous Familial Hypercholesteremia | | | Date of diagnosis: | | | Drug Treatment History (complete as applicable): | | | | | | Drug | Last prescribed dose | Start date | | End date (if applicable) | | atorvastatin | | | | | | ezetimibe | | | | | | rosuvastatin | | | | | | other (list drug name(s) below) | | | | | | | | | | | | | | | | | | | | | | | Section 3-PCSK9 Inhibitor Prescription Information | Drug name and strength: | | Directions: | | --- | --- | --- | | Please indicate PSCK9 treatment status | | | | Initial | Continuation; Date of treatment initiation: | | Section 4-Laboratory Information | LDL-C prior to initiation of PCSK9 treatment: mg/dL | Date level obtained:
(for first time requests, level must be from previous 60 days) | | --- | --- | | Current LDL-C: mg/dL * | Date level obtained:
(level must be from previous 60 days) | * Required for renewal requests only. Must have at least a 50% reduction in LDL-C compared to LDL-C level prior to PCSK-9 treatment initiation for patients with HeFH and at least a 30% reduction in LDL-C for patients with HoFH for renewal approval. Section 5-Prescriber Information and Signature | Prescriber Name
(Last, First) | | | Prescriber NPI | | | | | --- | --- | --- | --- | --- | --- | --- | | Address | | City | | | State | ZIP | | Prescriber license | Specialty
(if applicable) | | | Office Phone | | | | Preparer Name
(if other than prescriber) | | | | Office Fax | | | By signing below, I, the prescriber, certify that the information provided above is verifiable and accurate to the best of my knowledge. Prescriber Signature: Date: [SuperiorHealthPlan.com](SuperiorHealthPlan.com)[ ](SuperiorHealthPlan.com)SHP_20173879B

FAQs

What information is required in Section 1 (Patient Information)?

Section 1 requests the patient’s first name, last name, middle initial, date of birth, cardholder ID, and applicable drug allergies.

Which diagnoses can be selected in Section 2 (Patient History)?

Section 2 allows selecting one required diagnosis: heterozygous familial hypercholesteremia, clinical atherosclerotic cardiovascular disease, or homozygous familial hypercholesteremia.

What LDL-C requirements apply in Section 4 (Laboratory Information)?

Initial requests require an LDL-C prior to PCSK9 initiation and a current LDL-C level obtained within the previous 60 days. Renewal requests must show at least a 50% LDL-C reduction for HeFH or at least a 30% reduction for HoFH compared with baseline.

Sep 17, 2026

Uploaded by Jordan Avery