TX HHS Form 1357. Increlex Prior Authorization Request

The TX HHS Form 1357, Increlex Prior Authorization Request, is a critical document used by healthcare providers to request prior authorization for Increlex treatment in Medicaid fee-for-service patients. This form is only applicable to individuals enrolled in Medicaid fee-for-service and not managed care programs.

This form is designed to facilitate the prior authorization process for Increlex, a medication used to treat growth failure due to growth hormone gene deletion/deficiency or neutralizing bodies. The form requires prescribers to provide patient information, including diagnosis, laboratory test results, and treatment history. By completing this form, healthcare providers can ensure that patients receive timely access to necessary treatment while also adhering to Medicaid guidelines.

The TX HHS Form 1357 is issued by the Texas Health and Human Services (HHS) agency and must be submitted along with the Texas Standard Prior Authorization Request Form for Prescription Drug Benefits (TDI Form). Incomplete forms or failure to submit this addendum may result in delays in patient care and/or prior authorization denial. Healthcare providers can contact the Texas Prior Authorization Call Center at 866-469-8590 for assistance with completing the form.