Download Pituitary Growth Hormones Coverage Determination

Pituitary Growth Hormones Coverage Determination
Mail requests to:
Coverage Determination & Exceptions
PO Box 20002 Nashville, TN 37228
Fax requests to:
Request by phone:
(866) 845‐7267
(877) 813‐5595
FOR PROVIDER USE ONLY
Provider First Name:
Provider Phone:
Provider Address:
License Number:
Provider Last Name:
Provider Fax:
DEA Number:
NPI Number:
Member Name:
Member Address:
Member Phone:(H)
Member ID:
(C)
DOB:
RX
Drug:
Prescription Information
Dosage:
Frequency:
□ Brand
□ Generic
□ New Medication
Quantity:
□ Continuation (Provide Start Date)
Refills:
Diagnosis:





Decreased body growth – Prader-Willi Syndrome
Short-stature disorder (Idiopathic, SHOX deficiency, Noonan’s syndrome, Turner syndrome)
Growth hormone deficiency
Renal function impairment with growth failure
Other diagnosis not listed: ________________________________________________________
Administration Site: Patient's home:
Physician’s office:
Drug Supplied By:
Pharmacy:
Home infusion:
Long Term Care:
Physician's supply:
Skilled nursing:
Other:
Other:
Request for expedited review [24 hours]. By checking this box, I certify that applying the 72 hour
standard review time frame may seriously jeopardize the life or health of the member or the member's ability
to regain maximum function.
Provider Signature:
Date:
Created 08/26/2013