Growth Hormone (Gh) Therapy - Medical Necessity Request Form Page 3
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3Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
**Complete this page ONLY for Subsequent (Renewal) requests or for dosage changes**
General Information
Current Height: ________ Date Taken: _________
Previous Dose: _____________________________
Current Weight: ________ Date Taken: _________
New Dose: ________________________________
Requested Quantity: _________________________
Diagnosis Information (please select diagnosis and provide requested information below the diagnosis):
□ Pediatric GH deficiency, Isolated GH Deficiency, Pituitary Dwarfism, Hypopituitarism or Panhypopituitarism
- Has epiphyseal closure/fusion occurred? Yes or No
□ Chronic renal insufficiency
- Has member undergone renal transplantation?
□ Yes - Is the transplant failing? Yes or No
□ No
- Has epiphyseal closure/fusion occurred? Yes or No
□ Turner's syndrome
□ Noonan Syndrome
□ SHOX (short stature homeobox-containing) deficiency
OR
OR
- Has epiphyseal closure/fusion occurred? Yes or No
□ Prader-Willi syndrome
-Has epiphyseal closure/fusion occurred? Yes or No
□ Small for gestational age
- Has epiphyseal closure/fusion occurred? Yes or No
□ Adult GH deficiency *Please provide documentation of any of the below answered Yes
- Are IGF-1 levels below or within the normal range for age and sex? Yes or No
- Has there been an improvement in any of the following:
- blood lipid levels? Yes or No
- waist-to-hip ratio? Yes or No
- body composition? Yes or No
- quality of life? Yes or No
- Has there been a reduction of cardiovascular risk factors? Yes or No
□ Idiopathic short stature
- Has epiphyseal closure/fusion occurred? Yes or No
□ HIV/AIDS wasting syndrome
- Is member currently receiving and will continue to receive antiretroviral therapy? Yes or No
- How many weeks of therapy are being requested? _________________________________
□ Short bowel syndrome
- Is member receiving specialized nutritional support OR managed by a Gastroenterologist? Yes or No
□ Other (please specify): _______________________
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office.
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Rev. 03/16
HNJH Fax #: 888-567-0681
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