Form 1357, Increlex Prior Authorization Request

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Documents

Effective Date: 10/2024

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).