Documents
Instructions
Update: 10/2024
Purpose
For prescribing providers to request pharmacy prior authorization for Increlex (mecasermin). The prescriber or their staff faxes the form to the Medicaid-enrolled pharmacy, who then faxes it to the Texas Prior Authorization Call Center.
When to Prepare
- This form must accompany the Texas Department of Insurance Standard Prior Authorization Form (TDI Form NOFR002).
- Only use this form for people enrolled in Medicaid fee-for-service.
- The prescribing provider should sign and submit all requests. Please complete all requested information or document why information is not available.
Detailed Instructions
- Staff sends the form to the Medicaid-enrolled pharmacy, who then forwards the completed form by fax.
Transmittal
- Fax: 866-469-8590
Questions
- Direct questions about this form to the Texas Prior Authorization Call Center at 877-PA-TEXAS (877-728-3927).