Prior Authorization Worksheet For Prescribers Clinical Drug Review Program - New York State Medicaid Program Page 3
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1
2
3NEW YORK STATE MEDICAID PROGRAM
PRIOR AUTHORIZATION WORKSHEET FOR PRESCRIBERS
CLINICAL DRUG REVIEW PROGRAM
Prior Authorization Call Line 1- 877- 309-9493
C
LINICAL CRITERIA
SEROSTIM:
D
ose (based on weight, see chart below)
_
____ mg SC daily
Day supply (maximum 28 days)
_____
Does patient have clearly documented HIV infection or AIDS?
Is patient 18 years of age or older?
Is patient receiving at least 100% of estimated caloric requirement on current nutritional regimen?
Are you or have you consulted with an HIV specialist?
Does patient have unintentional weight loss of at least 5% or greater from baseline pre-morbid weight
or weigh an amount that indicates a recent significant weight loss has occurred (BMI<20kg/m2) in the
a
bsence of opportunistic infection?
Is patient on current anti-viral therapy with good viral suppression?
Does the patient have recent blood work to confirm an amylase level ≤ 3 times the upper normal limit, a
c
reatinine level ≤ 2mg/dl or a fasting triglyceride level ≤ 500mg/dl?
Does the patient have an active malignancy (other than Kaposi’s Sarcoma) or are they undergoing
systemic chemotherapy or being treated with interferon, anabolic steroids or investigational drugs?
Does the patient have evidence of GI bleeding, intestinal obstruction, malabsorption syndrome, or
s
evere liver dysfunction?
Does the patient have angina pectoris, coronary artery disease, congestive heart failure, renal failure, or
s
erious chronic edema?
Does the patient have a history of glucose intolerance or uncontrolled hypertension?
Have other treatment modalities been tried and failed?
Patient’s current weight in pounds
_
____lbs
Patient’s height in inches
_
____inches
Patient’s current Body Mass Index (BMI)
_____
SEROSTIM DOSING CHART:
WEIGHT RANGE
APPROPRIATE DOSE
> Over 121 pounds (>55 kilograms)
6 mg SC daily
99 to 121 pounds ( 45-55 kilograms)
5 mg SC daily
77 to 98 pounds (35-44 kilograms)
4 mg SC daily
For billing questions, call 1-800-343-9000
For clinical concerns or
Clinical Drug Review Program questions, visit
www
.nyhealth.gov
and
or call 1-877-309-9493
For Medicaid pharmacy policy and operations questions, call (518) 486-3209
Revised 9/06
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