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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.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/texas-standard-prior-authorization-form-pcsk9-inhibitors-pa-form/283935/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/texas-standard-prior-authorization-form-pcsk9-inhibitors-pa-form/283935.png","ImageObject",442,249,{"name":88,"@type":89},"Jordan Avery","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-29","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",7,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information is required in Section 1 (Patient Information)?","Question",{"text":109,"@type":110},"Section 1 requests the patient’s first name, last name, middle initial, date of birth, cardholder ID, and applicable drug allergies.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Which diagnoses can be selected in Section 2 (Patient History)?",{"text":114,"@type":110},"Section 2 allows selecting one required diagnosis: heterozygous familial hypercholesteremia, clinical atherosclerotic cardiovascular disease, or homozygous familial hypercholesteremia.",{"name":116,"@type":107,"acceptedAnswer":117},"What LDL-C requirements apply in Section 4 (Laboratory Information)?",{"text":118,"@type":110},"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.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},283935,1791511939,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},1099523882367,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Texas Standard Prior Authorization Form-PCSK9 Inhibitors  \nPlease complete and fax all required documents to Envolve Pharmacy Solutions at 1-833-423-2523 for prior authorization requests for Superior HealthPlan members.  \nSuperior follows the Texas Vendor Drug Program clinical prior authorization criteria for PCSK9 inhibitors.  \nSection 1-Patient Information  \n\n| First Name |  | Last Name |  | MI |\n| --- | --- | --- | --- | --- |\n| DOB | Cardholder ID |  | Applicable drug allergies |  |\n\nSection 2-Patient History  \n\n| Required Diagnosis (please check one of the following): |  |  |  |  |\n| --- | --- | --- | --- | --- |\n|  Diagnosis of Heterozygous Familial Hypercholesteremia |  |  | Date of diagnosis: |  |\n|  Clinical Atherosclerotic Cardiovascular Disease |  |  | Date of diagnosis: |  |\n|  Diagnosis of Homozygous Familial Hypercholesteremia |  |  | Date of diagnosis: |  |\n| Drug Treatment History (complete as applicable): |  |  |  |  |\n| Drug | Last prescribed dose | Start date |  | End date (if applicable) |\n|  atorvastatin |  |  |  |  |\n|  ezetimibe |  |  |  |  |\n|  rosuvastatin |  |  |  |  |\n|  other (list drug name(s) below) |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n\nSection 3-PCSK9 Inhibitor Prescription Information  \n\n| Drug name and strength: |  | Directions: |\n| --- | --- | --- |\n| Please indicate PSCK9 treatment status |  |  |\n|  Initial |  Continuation; Date of treatment initiation:   |  |\n\nSection 4-Laboratory Information  \n\n| LDL-C prior to initiation of PCSK9 treatment:   mg/dL | Date level obtained:  \u003Cbr>(for first time requests, level must be from previous 60 days) |\n| --- | --- |\n| Current LDL-C:   mg/dL * | Date level obtained:  \u003Cbr>(level must be from previous 60 days) |\n\n* 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.  \nSection 5-Prescriber Information and Signature  \n\n| Prescriber Name\u003Cbr>(Last, First) |  |  | Prescriber NPI |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Address |  | City |  |  | State | ZIP |\n| Prescriber license | Specialty\u003Cbr>(if applicable) |  |  | Office Phone |  |  |\n| Preparer Name\u003Cbr>(if other than prescriber) |  |  |  | Office Fax |  |  |\n\nBy signing below, I, the prescriber, certify that the information provided above is verifiable and accurate to the best of my knowledge.  \nPrescriber Signature: Date:  \n[SuperiorHealthPlan.com](SuperiorHealthPlan.com)[ ](SuperiorHealthPlan.com)SHP_20173879B","cbCaiv8f158NPCq5","https://ap.wps.com/l/cbCaiv8f158NPCq5","pdf",1120471,"English","# Section 1 - Patient Information\n# Section 2 - Patient History\n# Section 3 - PCSK9 Inhibitor Prescription Information\n# Section 4 - Laboratory Information\n# Section 5 - Prescriber Information and Signature","[{\"question\":\"What information is required in Section 1 (Patient Information)?\",\"answer\":\"Section 1 requests the patient’s first name, last name, middle initial, date of birth, cardholder ID, and applicable drug allergies.\"},{\"question\":\"Which diagnoses can be selected in Section 2 (Patient History)?\",\"answer\":\"Section 2 allows selecting one required diagnosis: heterozygous familial hypercholesteremia, clinical atherosclerotic cardiovascular disease, or homozygous familial hypercholesteremia.\"},{\"question\":\"What LDL-C requirements apply in Section 4 (Laboratory Information)?\",\"answer\":\"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.\"}]","Texas Standard Prior Authorization Form - PCSK9 Inhibitors - PA Form | PDF",1789622836]