Serostim Pa Form 04-26-06 - Prescriber'S Statement Of Medical Necessity - Serostim For Treatment Of Aids Wasting Syndrome - Patient Information

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MARYLAND PHARMACY AND MEDICAL ASSISTANCE PROGRAMS
Tel # 410-767-1693- Fax# 410-333-7049
PRESCRIBER’S STATEMENT OF MEDICAL NECESSITY
®
Serostim
for Treatment of AIDS Wasting Syndrome
Patient Information
Patient name:______________________ Address:____________________________________
MA ID#:__________________________
____________________________________
Tel #: (________)__________-________
____________________________________
Date of birth:____________Height_______ft______inch
(not covered for pediatric patients)
Current weight:____________lbs or ________kg Date of measurement:______/_____/___
Premorbid body weight:_________lbs or _________kg; Date of measurement:____/_____/____
Weight loss:_________lb (Pre-morbid body weight - Current Weight)
Percentage of weight loss:_____% (at least 10% weight loss over 12 months)
Above referenced patient:
* has clearly documented HIV infection/ has been diagnosed with AIDS Wasting: Yes__No__
* is currently receiving antiviral therapy: Yes__ No__ List current antiviral therapy in use:
_________________________________________________________________________
* is receiving adequate intake on current nutrition regimen:
Yes___ No___
* has tried appetite stimulants: Yes__ No__;
List all appetite stimulants tried before
growth hormone therapy:______________________________________________________
Is patient testosterone deficient? Yes_____No_____
List other nutritional interventions/response:__________________________________________
Inadequate or no weight gain ____
Inadequate or no increase in lean body mass ____
®
Has patient been on Serostim
before? Yes___No__. If yes, date of last injection: ___________
®
For both 1st & 2nd course of Serostim
, submit copy of bioelectric impedance analysis if
®
available. For a 2nd course of Serostim
, which is currently not FDA, approved, submit letter of
recommendation by an HIV infectious disease specialist.
Prescription
®
Rx Serostim
(somotropin) ___ mg daily SQ at hs- Max length of therapy = 12 weeks
Dispense: #___vials*
___4mg vials; ___5mg vials; __ 6mg vials
Recommended dosage guidelines:
<35kg = 0.1mg/kg/day ; 35-45 kg = 4mg ;
45-55 kg = 5mg ;
>55kg = 6mg
Due to the drug’s high cost, only one two-week supply at a time is authorized by the Department,
up to a maximum of 12 weeks of therapy. If patient continues to lose weight at week Two,
reevaluate for concurrent opportunistic infections/other clinical events. Stop therapy.
®
I certify that this treatment is medically necessary and meets the FDA-approved Serostim
labeled use
guidelines. Supporting documentation in the patient’s medical record is available for State audits.
_________________________Prescriber’s address:_________________________________________
Prescriber’s signature
__________________________________________
Name:________________________MD
Date:____________Tel#: (______)________-________
Specialty: ___________________License #___________
Fax# (_____)_______-________
______________________________________________________________________________
Pharmacy name:___________________________
Phone #: (_________)___________-____________ Fax # (________)__________-_____________
* Adapted from Treatment Guidelines for HIV-Associated Wasting developed by the Consensus
Development Panel, which met in New York City, NY, July 26, 2000.
* Implemented 2/20/01
Serostim PA Form 04-26-06

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