Fillable Growth Hormone Pharmacy Prior Authorization Request Form (Mercy Care)

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Growth Hormone Pharmacy Prior Authorization Request Form (Mercy Care)

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The Growth Hormone Pharmacy Prior Authorization Request Form (Mercy Care) form is 4 pages long and contains:

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  • 32 check-boxes
  • 205 other fields

Country of origin: US
File type: PDF

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Fax completed prior authorization request form to 800-854-7614 or submit Electronic Prior Authorization through
CoverMyMeds® or SureScripts.
All requested data m ust
be provided. Incomplete forms or forms without the chart notes will be returned
Pharmacy Cov
erage
Guidelines are available at
www.mercycareaz.org/providers/completecare-forproviders/pharmacy
Growth Hormone
Pharmacy Prior Authorization Request Form
Do not copy for future use. Forms are updated frequently.
REQUIRED: Chart note
s that include weight, height, growth velocity and lab values (GH levels, IGF-1 / IGFBP-3), stim test results, bone age
Member Information
Member Name (first & last):
Date of Birth:
Gender:
Female
Height:
Member ID:
City:
State:
Weight:
Prescribing Provider Information
Provider Name (first & last):
Specialty:
NPI#
DEA#
Office Address:
City:
State:
Zip Code:
Office Contact:
Office Phone
Office Fax:
Dispensing Pharmacy Information
Pharmacy Name:
Pharmacy Phone:
Pharmacy Fax:
Requested Medication Information
Preferred Agents:
Norditropin ☐
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Genotropin
Non-Preferred Agents:
Omnitrope Vials
Humatrope
Saizen
Serostim
Tev-Tropin
Nutropin
Valtropin
Zorbtive (somatropin)
Other, please specify:
Are there any contraindications to formulary medications?
Yes
No
(if yes, please specify):
New
request
Continuation
of therapy
Medication request is NOT for an FDA-approved, or compendia-
supported diagnosis (circle on e): Yes
No
What medication(s) have been tried and failed for this diagnosis?
(please specify):
What is the diagnosis ICD-10 Code?
Diagnosis:
Directions for Use:
Strength:
Dosage Form:
Quantity:
Day Supply:
Duration of Therapy/Use:
Turn-Around Time for Review
Standard – (24 hours)
Urgent – If waiting 24 hours for standard decision could seriously harm life, health, or ability to regain
maximum function, you can ask for an expedited decision.
Signature: ________________________________________________
________________
Clinical Information
Was there inability OR disability to use vial
formulation (example: visual impairment)?
Yes
No
Was treatment for indication not supported by
preferred Growth Hormone product?
Yes
No
Was there history of neonatal hypoglycemia
associated with pituitary disease?
Yes
No
Was there history of irradiation, surgery OR trauma to
hypothalamic-pituitary area?
Yes
No
Was there defined CNS pathology confirmed by MRI or CT?
Yes
No
Pediatric Growth Hormone Deficiency
Effective: 04/01/2020 C4582-A, C6653-A, C6655-A 12-2019 Page 1 of 4
Proprietary
click to sign
signature
click to edit
Is height >2 standard deviations below mid parental height (projected height)?
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Yes
No
N/A
Is height >2.25 standard deviations below population mean for age and gender?
Yes
No
N/A
Is growth velocity >2 standard deviations below population mean for age and gender?
Yes
No
N/A
Is bone age compared to chronological age ≥ 2 standard deviations below mean for age and gender?
Yes
No
N/A
Has member undergone 2 GH stimulation tests
(for example, Arginine, Clonidine, Glucagon,
Insulin, Levodopa, GhRh)?
Yes
No
N/A
Were GH response
values < 10 mcg/L?
Yes
No
N/A
Was ONE abnormal GH test enough for child with defined CNS pathology, multiple pituitary hormone deficiency,
history of irradiation OR genetic defect affecting GH axis?
Yes
No
N/A
Is member < 1 year of age AND IGF-1 or IGFBP-3 is below age AND gender adjusted normal range as provided
by physician’s lab?
Yes
No
N/A
Are epiphyses open (confirming open
growth plates in members who are
over 12 years of age)?
Yes
No
N/A
Were other pituitary hormone deficiencies
ruled out (for example, hypothyroidism,
chronic ischemic disease)?
Yes
No
Renewal Request ONLY:
Did provider submit documentation for previous height,
current height AND expected adult height goal?
Yes
No
Did height increase at least 2.5cm per year
OR 4.5cm per year?
Yes
No
Was expected final height NOT achieved?
Yes
No
Is bone age <16 years for males OR <14
years for female?
Yes
No
Are growth (epiphyseal) plates still open?
Yes
No
Prader-Willi Syndrome
Is epiphyses open (confirmation of open
growth plates in member > 12 years of age)?
Yes
No
N/A
Is growth velocity >2 standard deviations
below population mean for age AND gender?
Yes
No
Renewal Request ONLY:
Is there documentation supporting positive response to therapy (for example, increase in total lean body mass, decrease
in fat mass) OR above growth hormone renewal requirements are met?
Yes
No
Turner Syndrome
Is this request for a Female that is >2 years
of age AND bone age is <14 years?
Yes
No
Is growth velocity >2 standard deviations below
population mean for age and gender?
Yes
No
Are Epiphyses open (confirmation of open growth plates in patients over 12 years of age)?
Yes
No
N/A
Noonan Syndrome
Is GV >2 standard deviation below
population mean for age AND gender?
Yes
No
Is bone age compared to chronological age ≥2
standard deviations below mean for age AND gender?
Yes
No
Are epiphyses open (confirmation of open growth plates in member over 12 years of age)?
Yes
No
N/A
Short Stature with SHOX Deficiency
Was diagnosis confirmed by
genetic testing?
Yes
No
Is bone age compared to chronological age ≥2 standard deviations
below mean for age AND gender?
Yes
No
Epiphyses are open (confirmation of open
growth plates in patients over 12 years of age)?
Yes
No
Is GV >2 standard deviations below population
mean for age AND gender?
Yes
No
Growth Failure with Chronic Renal Insufficiency OR Chronic Kidney Disease Prior to Renal Transplantation
Prior to start with GH therapy, were the existing metabolic derangements such as malnutrition, zinc deficiency AND
secondary hyperparathyroidism corrected?
Yes
No
Was bone age compared to chronological age ≥2
standard deviations below mean for age and gender?
Yes
No
Is growth velocity >2 standard deviations
below population mean for age and
gender?
Yes
No
Growth Failure in Children Small for Gestational Age
Did child fail to achieve catch up growth in first 24 months of life (by 2 years of age) using a 0-36-month growth chart?
Yes
No
Is member below the 3rd percentile for gestational age
(>2 standard deviations below population mean) for
birth weight AND length?
Yes
No
Did member height remain below 3rd
percentile (> 2 standard deviations below
population age AND gender)?
Yes
No
Renewal Request ONLY:
Did provider submit documentation for previous height,
current height AND expected adult height goal?
Yes
No
Did height increase at least 2.5cm per year
OR 4.5cm per year?
Yes
No
Was expected final height NOT achieved?
Yes
No
Is bone age <16 years for males OR <14
years for female?
Yes
No
Are growth (epiphyseal) plates still open?
Yes
No
Transition Phase Adolescent Members
Effective: 04/01/2020 C4582-A, C6653-A, C6655-A 12-2019 Page 2 of 4
Proprietary
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Is adolescent between ages 10 to 19 as defined by World Health Organization?
Yes
No
Did member attain expected adult height?
Yes
No
Did bone radiograph show closed epiphyses?
Yes
No
Member is at high risk of GH?
deficiency due to childhood-onset
from ONE of the following:
Hypothalamic-Pituitary
structural defect or tumor
At least 3 deficiencies of anterior pituitary
hormones (FSH / LH, TSH, ACTH,
Prolactin), pan-hypopituitarism
Genetic cause of GH
Is IGF-1 below age AND gender adjusted normal range as provided by physician’s lab?
Yes
No
Member has stopped GH therapy for at least ONE month AND
undergone ONE provocative GH stim test confirming transition
phase GH deficiency AND ONE of the following peak values:
Insulin Tolerance Test:
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≤5 ng/ml
Glucagon:
≤3 ng/mL
Arginine:
≤0.4 ng/mL
Arginine + GHRH:
☐ ≤11 ng/mL if BMI is < 25 kg/m2
☐ ≤8 ng/mL if BMI ≥25 and <30 kg/m2
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≤4 ng/mL if BMI ≥30 kg/m2
Renewal Request ONLY:
Is there documentation supporting positive response to therapy (for example, increase in total lean body mass, increased
exercise capacity OR increased IGF-1 levels) AND documentation is submitted with request?
Yes
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No
Adult Growth Hormone Deficiency
Did provider submit documentation supporting diagnosis, stim test results, and IGF-1 levels?
Yes
No
Is there a diagnosis of childhood-onset GHD?
Yes
No
Is there a diagnosis of adult-onset GHD?
Yes
No
Is there documentation supporting hormone
deficiency is due to hypothalamic-pituitary
disease from organic or known causes?
Yes
No
Was there 1 GH stim test confirming adult GH
deficiency (insulin tolerance test, arginine+GHRH,
glucagon, arginine)?
Yes
No
Member has ONE of the
following peak value
tests:
Insulin tolerance t est:
≤5 ng/ml
Arginine+GHRH:
≤11 ng/mL if BMI is < 25 kg/m2
☐ ≤8 ng/mL if BMI ≥25 and <30 kg/m2
≤4 ng/mL if BMI ≥30 kg/m2
Glucagon:
≤3 ng/mL
Arginine:
≤0.4 ng/mL
Macimorelin:
≤2.8 ng/mL
Is there at least 3 deficiency of anterior pituitary
hormones (FSH/LH, TSH, ACTH, Prolactin),
pan-hypopituitarism?
Yes
No
Is IGF-1 below age AND gender adjusted normal
range as provided by physician’s lab?
Yes
No
Renewal Request ONLY:
Is there documentation supporting positive response to therapy (for example, increase in total lean body mass, increased
exercise capacity OR increased IGF-1 levels) AND documentation is submitted with request?
Yes
No
HIV-Associated Cachexia or Wasting
Is there documentation of BMI, weight, and ideal body
weight prior to start of therapy and then after starting
Serostim?
No
Is member on current use of anti-
retroviral therapy?
Yes
No
Was there inadequate response, intolerable side effects,
or contraindication to megestrol acetate or dronabinol?
No
Is the BMI <20 kg/m2 prior to starting
Serostim?
Yes
No
Was there weight loss due to other causes such as depression, mycobacterium avium complex, chronic infectious
diarrhea, or malignancy with exception of Kaposi’s sarcoma limited to skin or mucous membranes?
Yes
No
Member has unintentional weight loss of >10% over last 12 months
or >5% over last 6 months?
Yes
No
Is weight <90% of the lower limit
of ideal body weight?
Yes
No
Renewal Request ONLY:
Is there documentation supporting positive response to
therapy (BMI has improved or stabilized)?
Yes
No
Is member on current anti-retroviral
therapy?
Yes
No
Short Bowel Syndrome
Is member currently receiving specialized nutrition
support (IV parenteral nutrition, fluid AND micronutrient
supplements)?
Yes
No
Was 4 weeks of treatment with Zorbtive
previously received?
Yes
No
Additional information the prescribing provider feels is important to this review. Please specify below or submit medical records
Effective: 04/01/2020 C4582-A, C6653-A, C6655-A 12-2019 Page 3 of 4
Proprietary
Signature affirms that information given on this form is true and accurate and reflects office notes.
Prescribing Provider’s Signature: Date: ___________________________________________________________________
Please note: Incomplete forms or forms without the chart notes will be returned
Office notes, labs, and medical testing relevant to the request that show medical justification are required.
Standard turnaround time is 24 hours. You can call 800-624-3879 to check the status of a request.
Effective: 04/01/2020 C4582-A, C6653-A, C6655-A 12-2019 Page 4 of 4
Proprietary
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Growth Hormone Pharmacy Prior Authorization Request Form (Mercy Care)

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Completed 31 July 2021

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