Form 1327, Growth Hormone Agents Standard PA Addendum (CSHCN)

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Effective Date
11/2021
Document
1327.pdf (222.2 KB)

Instructions

Updated: 11/2021

Purpose

The Children with Special Health Care Needs (CSHCN) Services Program covers growth hormones for people with specific diagnoses involving growth hormone deficiency. If an initial or extension request cannot be approved based on the above criteria, the approval request may be sent for medical review and reconsideration to program staff for medical review and reconsideration.

Procedure

When to Prepare

Prescribing providers only use this form for people enrolled in the CSHCN Services Program. A program-approved provider must complete and sign this form annually certifying that the individual requires these medications.

Providers should complete all requested information or document why the information is not available. Providers must submit Form 1327 and Texas Standard Prior Authorization Request Form for Prescription Drug Benefits (PDF).

Transmittal

Providers should send the form to the CSHCN-enrolled pharmacy, who then forwards the completed form by fax or mail:

Fax: 512-776-7238

Mail:

Texas Health and Human Services
Children with Special Health Care Needs Services Program (MC-1938)
P.O. Box 149347
Austin, TX 78714-9347

Questions

Refer comments or questions about this form to the CSHCN Services Program at 800-252-8023.