Growth Hormone (Gh) Prior-Authorization Request, Initiation And Continuation Of Gh Therapy-Approval Of The Non-Preferred Drug

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MARYLAND MEDICAID PHARMACYPROGRAM

PH 1-800-932-3918

FAX 1-866-440-9345

(GH) P

-A

ROWTH

ORMONE

RIOR

UTHORIZATION

EQUEST

GH T

- A

-P

NITIATION AND

ONTINUATION OF

HERAPY

PPROVAL OF THE

REFERRED

RUG

AGE

Incomplete forms will be returned.

Section I- Patient Information

Name:_______________________________________ MA ID#:____________ DOB:_________ Phone:____________ Other insurance:_________________________

Section II- Prescriber Statement of Medical Necessity/Drug/Clinical Information

Prescriber:________________________________________ Ph.:____________ Fax:____________ Address:_________________________________________________

Endocrinologist or nephrologist

Yes  No 

Estimated length of GH therapy:_______________________________________________

I certify that this treatment is medically necessary and meets the guidelines of the Maryland Medicaid Program. I will be supervising the patient’s treatment. Supporting

documentation is available in the patient record.

Prescriber’s Signature:___________________________________________

Date: __________

License #: ___________________________________

Initial request 

Renewal 

Drug/Dosage frequency:____________________________

The Preferred drugs are Norditropin, Nutropin, Nutropin AQ, and Genotropin. Complete Section III if request is for a non-preferred drug.

Patient’s weight: _____lbs or_____kgs Date patient last seen:____________ Primary diagnosis:_________________________________ (Do not use ICD-9)

Confirmed by a board certified endocrinologist or nephrologist?

Yes  No 

Diagnostic tests: GH deficiency (GHD) confirmed with provocative testing and IGF-1 level for both children and adults with GHD:

 Adult with childhood onset GHD or with additional pituitary hormone deficits- 1 stimulating test required

 Adult and children with suspected GHD with no other pituitary hormone deficits- at least 2 stimulating tests required

Test 1: type__________________

Results: _______mg/ml- Normal range: ________________

Test Date: __________

Test 2: type__________________

Results: _______mg/ml- Normal range: ________________

Test Date: __________

As provocative testing, ITT is required unless contraindicated. If contraindicated (seizures, CAD, abnormal EKG with history of IHD or CVD, and not advised

for those>age 60), documentation must be provided and an alternative test result (arginine, glucagon, GH releasing hormone, L-dopa and combination of

these agents, excluding clonidine) may be substituted. For patients with Chronic Renal Insufficiency (CRI) on dialysis, only an IGF-1 level is required.

Insulin-Like Growth Factor-1 (IGF-1) level (required annually):

________mg/ml

Date: ____________

Is there a contraindication to Insulin Tolerance Test (ITT)?

Yes  No 

If yes, state reason:

______________________________________________________________________________________________________________

If request is for adult GH therapy, skip items 5&6 below.

If request is for a child, is the patient’s height less than the 3rd percentile, or if 2.00 standard deviation (SD) or more below mean height for chronological age?

Yes  No 

Height: ____ft _____in

Percentile ______

Attach copy of growth chart.

Bone age: ______ ; Chronological age:______

Date of most recent radiology report:_______________

Is bone age < chronological age <=- 16 yrs (boys);<= 14 yrs (girls)?

Yes  No 

Has bone fused? Yes  No 

For adults requiring GH therapy, provide results of bone density test, if done- T score _____on DEXA testing or _____ SD by WHO

Has the patient been screened for intracranial malignancy/tumor? (If no, request will be denied)

Yes  No 

If a h/o of malignancy exists, has it been free of recurrence for at least the past 6 months?

Yes  No 

No malignancy

Does the patient have any of the following contraindications? If any of these apply, request will be denied.

 Pregnancy  Proliferative/preproliferative diabetic retinopathy;  Pseudotumor cerebri or benign intracranial HTS___

 Status/post renal transplantation;  Untreated chronic disease causing growth failure (i.e. hypothyroidism, liver disease, etc.) Explain:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is patient on: Corticotropin? Yes  No 

Systemic glucocorticoids? Yes  No

Antitumor chemotherapy? Yes  No 

10. Results of thyroid function tests (required every 6 months):

____________________________________________________________________________________________________________________________________________

11. List any other pertinent lab tests done with results:____________________________________________________________________________________

Section III- Prior-Auth of Non-Preferred Drugs

If a preferred drug is selected, skip this Section. The non-preferred drugs are: Omnitrope, Saizen, Tev-Tropin, Serostim, Humatrope, and Zorbtive. These

products are synthetic somatropin of recombinant DNA origin, considered therapeutically equivalent to endogenous growth hormones and therefore

interchangeable based on their international unit dosing equivalency. They vary in dosage strengths and forms, added preservatives, length of stability after mixing,

and FDA-approved indications. Prescribers should only use a non-preferred drug when absolutely necessary. Patients who have been receiving a preferred drug

that has become non-preferred do not need to be switched to an agent on the preferred drug list. If prescribers must use a non-preferred drug for a patient’s initial

growth hormone therapy, please provide valid reasons for selecting the non-preferred drug:

_______________________________________________________________________________________________________________________________