TX HHS Form 1357. Increlex Prior Authorization Request

The TX HHS Form 1357, Increlex Prior Authorization Request, is a crucial document for healthcare providers to obtain approval for treatment with Increlex. This form helps solve the problem of obtaining prior authorization for prescription medication benefits in Medicaid fee-for-service programs.

This form is typically used by prescribers or their designees to request prior authorization for Increlex therapy. The form requires specific information, including patient demographics, prescriber details, and medical history. Key features include the diagnosis of growth failure due to growth hormone gene deletion/deficiency/mutation or neutralizing bodies, low growth hormone levels, and height standard deviation score. The form also includes a section for expedited review requests, which allows prescribers to certify that applying the standard review time may seriously jeopardize the life or health of the patient.

To complete this form, healthcare providers must fax both Form 1357 and the Texas Standard Prior Authorization Request Form (TDI Form) to the Texas Prior Authorization Call Center at 866-469-8590. Incomplete forms or failure to submit this addendum may cause delays in patient care and/or prior authorization denial. It is essential for prescribers to follow the instructions carefully to ensure timely processing of the request.

• This form is only for people enrolled in Medicaid fee-for-service programs.
• Contact the appropriate MCO (Managed Care Organization) for forms and instructions if the patient is enrolled in managed care.