Growth Hormone (Gh) Prior-Authorization Request, Initiation And Continuation Of Gh Therapy-Approval Of The Non-Preferred Drug Page 2
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1
2MARYLAND MEDICAID PHARMACYPROGRAM
1-800-932-3918
FAX 1-866-440-9345
G
H
(GH) P
-A
R
ROWTH
ORMONE
RIOR
UTHORIZATION
EQUEST
I
C
GH T
- A
N
-P
D
NITIATION AND
ONTINUATION OF
HERAPY
PPROVAL OF THE
ON
REFERRED
RUG
P
2
2
AGE
OF
Incomplete forms will be returned.
Section IV- Children GH Therapy Evaluation- (If adult, skip this section and complete Section V).
Diagnoses:
Patient must have one of the following primary indications listed below. Please check applicable diagnosis:
Documented growth hormone deficiency
Turner Syndrome- Is diagnosis confirmed by karyotyping?
Yes No
Prader Willi Syndrome- Is diagnosis confirmed by appropriate chromosomal testing?
Yes No
Submit documentation of chromosomal abnormality. No need for provocative testing. Reassess need for continued long-term therapy in obese patients and those
with severe respiratory&vascular complications.
Growth deficiency due to chronic/irreversible renal insufficiency. Is patient on dialysis?
Yes No
If no, request will be denied.
If none of the above, explain:
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Continuation of therapy: Provide the following:
Date of last office visit: ______________________
Date when GH therapy was initiated: _____________________
Growth chart (Attach)- Height <25
th
percentile of normal height for gender?
Yes No
If goal of 25
th
percentile of normal height has been achieved, please reassess and provide rationale for patient’s continued GH therapy:
________________________________________________________________________________________________________________________
Epiphyses open? Yes No
Anticipated length of therapy:____________________________________________________________________
Height velocity >= 2.5cm/yr over previous untreated rate
Yes No
Height velocity measured over at least 6 months with at least 2 measurements: _______ cm per ______ months.
Bone age per radiological report: ______________
Date of test: ________________
Chronological age: ____________
Normal thyroid function test?
Yes No
IGF-1 level: _________ ng/ml
Test date: _________
Based on results of recommended lab tests, thyroid function tests and IGF-1 levels (both initially and at least annually thereafter), is continuation of GH therapy
justified?
Yes No
IGF-1 level: ________ ng/ml
Comment on GH therapy efficacy, adverse effects, any compliance issues:
___________________________________________________________________________________________________________________________
Section V - Adult Growth Hormone Therapy Evaluation
Diagnoses: Patient must have one of the following primary indications. Check applicable diagnosis:
Adult with childhood onset of growth hormone deficiency
Adult onset of growth hormone deficiency with no other deficiencies
Adult onset of growth hormone deficiency with other pituitary hormone deficiencies
If none of the above, explain:
________________________________________________________________________________________________________________________________________________________________________________________
Continuation of therapy: Provide the following:
1.
IGF-1 level (within the past 12 months): _________ ng/ml
Date of test: ___________
2.
Based on annual evaluation of fasting lipid profile, BUN, fasting glucose, electrolyte levels, bone density testing (recommended after the first year, then every 3
years thereafter), is continuation of GH therapy justified?
Yes No
Anticipated length of therapy: ________________________________________
Comment on GH therapy efficacy, adverse effects, any compliance issues:
3.
_______________________________________________________________________________________________________________________________
INTERNAL USE
Clinical PA:
Approved: _________ / _________
Approval is for 6 months from: ________________ to _______________
(Medical necessity for growth hormone therapy must be renewed every 6 months)
Rejected: _________ / _________
Patient does not meet criteria.
PDL PA (Use of Non-Preferred Drug):
Approved
Rejected - Invalid reason
Rev. 03/2011
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