Circle Yes or No Y N. [If yes, skip to question 30.] 2. Is this request for a child? Y N. [If no, skip to question 20.]

Transcription

1 05/20/2015 Prior Authorization MERC CARE PLA (MEDICAID) Growth Hormone (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to Mercy Care Plan at Please contact Mercy Care Plan at with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of Growth Hormone (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (specify drug) Quantity Frequency Strength Route of Administration Patient Information Patient ame: Patient ID: Patient Group o.: Patient DOB: Patient Phone: Prescribing Physician Expected Length of therapy Physician ame: Specialty: PI umber: Physician Fax: Physician Phone: Physician Address: City, State, Zip: Diagnosis: ICD Code: Please circle the appropriate answer for each question. Question 1. Has this plan authorized this medication in the past for this patient (i.e., previous authorization is on file under this plan)? Circle es or o [If yes, skip to question 30.] 2. Is this request for a child? [If no, skip to question 20.] 3. Is growth hormone prescribed by a specialist based on the condition treated (e.g., pediatric endocrinologist, nephrologist)?

2 Circle es or o 4. Does the patient have any of the following? Closed epiphyses (e.g., bone age greater than14 yrs, Tanner Stage 4-5) \ Untreated hypothyroidism, inadequate caloric intake/malnutrition/eating disorder, or other untreated condition that could be contributing to growth failure 5. Has the patient s baseline height, weight, and growth velocity been recorded within the last 3 months? Please document weight, height and growth velocity: 6. Is the patient s height more than 2 standard deviations (SDS) below the mean for age and sex? 7. Is the patient s pretreatment growth velocity below normal for age and sex? 8. Does the patient have a diagnosis of idiopathic short stature? 9. Does the patient have a diagnosis of Turner Syndrome, Prader-Willi Syndrome, SHOX deficiency, or oonan Syndrome? [If no, skip to question 11.] 10. Has the diagnosis been confirmed by genetic testing? [o further questions.] 11. Does the patient have a diagnosis of chronic renal insufficiency? [If no, skip to question 14.] 12. Has the patient undergone a kidney transplant?

3 13. Have metabolic abnormalities (such as malnutrition, acidosis, secondary hyperparathyroidism and hyperphosphatemia) been corrected if they exist? Circle es or o [o further questions.] 14. Does the patient have a diagnosis of small for gestational age (SGA) with failure to catch up by 2 years of age? [If no, skip to question 16.] 15. Does the patient meet one of the following: Birth weight or length below the 3rd percentile for gestational age \ Birth weight less than 2500 gm AD the gestational age at birth was more than 37 weeks. Please document GA, birth weight and/or length: ote: Growth hormone therapy for children with intrauterine growth restriction not meeting diagnostic criteria for small for gestational age above is considered experimental and investigational. [o further questions.] 16. Does the patient have growth hormone deficiency that is caused by a structural or developmental abnormality, genetic disorder, or an acquired cause (e.g., cranial irradiation, brain surgery, CS infection)? [If no, skip to question 18.] 17. Did the patient have a peak growth hormone level below 10 mcg/l on a fasting growth hormone stimulation test using at least one of the following provocative agents: arginine, glucagon, clonidine, or levodopa? Please provide peak level and agent(s) tried: [o further questions.] 18. Does the patient have a diagnosis of idiopathic growth hormone deficiency (e.g., OT due to a congenital disease, renal insufficiency, or SGA)? [If no, skip to question 20.]

4 19. Did the patient have a peak growth hormone level below 10 mcg/l on a fasting growth hormone stimulation test using 2 of the following provocative agents: arginine, glucagon, clonidine, or levodopa? Please provide peak level and agent(s) tried: Circle es or o [o further questions.] 20. Does the patient have a diagnosis of childhood-onset idiopathic GHD? [If no, skip to question 23.] 21. Was the IGF-1 level drawn at least 1-3 months after discontinuing previously initiated growth hormone therapy? Please provide baseline IGF-1 and date drawn: 22. Was the patient retested for growth hormone deficiency 1-3 months after discontinuing growth hormone therapy? [If yes, skip to question 29.] 23. Does the patient have a diagnosis of childhood-onset GHD due to a known cause? (i.e. structural lesions, genetic disorders, acquired causes). Please provide cause of GH deficiency: [If no, skip to question 25.] 24. Did the patient have a baseline serum IGF-1 level drawn? Please provide baseline IGF-1 level and date drawn: [o further questions.] 25. Does the patient have a diagnosis of adult-onset GHD due to a known cause (e.g., surgery, cranial irradiation, panhypopituitarism)? Please provide cause: [If no, skip to question 27.]

5 26. Did the patient have a baseline serum IGF-1 level drawn? Please provide baseline IGF-1 level and date drawn: Circle es or o [If yes, skip to question 29.] 27. Is growth hormone deficiency due to a traumatic brain injury or aneurysmal subarachnoid hemorrhage? 28. Was growth hormone stimulation testing performed at least 12 months after the event? 29. Does the patient meet one of the following? Please provide peak level and testing method: Patient has undergone growth hormone stimulation testing utilizing the insulin tolerance test AD peak growth hormone level was less than or equal to 5 mcg/l \ Patient has undergone growth hormone stimulation testing utilizing glucagon as the provocative agent AD peak growth hormone level was less than or equal to 3 mcg/l [o further questions.] 30. Is the reauthorization request for a child? [If no, skip to question 33.] 31. Is there any evidence of epiphyseal closure or that final height has been achieved? 32. Is the patient s growth velocity greater than 5 cm/year OR less than 5 cm/yr but the dose will be increased? Please document current dose, height, weight, and growth velocity: [o further questions.]

6 33. Is the patient s serum IGF-1 at a stable target range? Please document IGF-1 level and date drawn: Circle es or o 34. Is the dose of growth hormone being adjusted to achieve target IGF-1? Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature Prescriber (Or Authorized) Signature Date Date