Prior Authorization Request Form (Growth Hormone) - Utah Department Of Health
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1UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM
GROWTH HORMONE ADULT-AIDS
Patient name:___________________________________Medicaid ID #:________________________________
Prescriber Name:_________________Prescriber NPI#:_____________ Contact person:____________________
Prescriber Phone#:___________________Extension/Option:________________ Fax#:____________________
Pharmacy:______________________Pharmacy Phone#:________________Pharmacy Fax #:_______________
Requested Medication:______________________________Strength:__________Frequency/Day:___________
All information to be legible, complete and correct or form will be returned
_________________________________________________________________________________________
855-828-4992
FAX REQUIRED DOCUMENTATION FROM PROGRESS NOTES
TO
CRITERIA:
Adult age 19 and over
Adult onset - AIDS Wasting indication only.
Body Mass Index is less than 20, BMI = wt times 704 divided by height squared (in inches)
Patient must be taking antiretroviral medications
Initial weight__________, Initial Height__________, Weight after 60 day trial__________
Rule out causes of weight loss including hypogonadism, opportunistic infections, diarrhea, inadequate
nutritional intake, malabsorption, and thyroid abnormalities.
(For men) Rule out hypotestosterone levels since hypogonadism is common among HIV infected
individuals.
Patient must be able to maintain 100% of daily nutritional intake. For patients receiving enteral or
parenteral nutrition, the patient must be weight stable for two months.
Patient must not have an untreated or suspected systemic infection or persistent fever > 101 F during the
30 days prior to evaluation of weight loss.
Patient must not have any signs or symptoms of gastrointestinal malabsorption or blockage unless on
total parenteral nutrition
Patient must not have active malignancy, except for Kaposi’s Sarcoma (KS).
AUTHORIZATION:
Initial trial 60 days.
RE-AUTHORIZATION:
Fax copy of current prescription and history and physical showing weight gain during trial period. With
appropriate progress, the patient may receive an additional four weeks of therapy. If the patient continues to
show progress, additional prior authorizations are granted in six week periods only to a maximum of twelve
weeks per any six month episode.
9/13/10
https://medicaid.utah.gov/pharmacy/
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