Download Last updated 3/4/2016 Growth Hormones

Growth Hormones Questionnaire
Please complete and fax back to 405-280-5613
This form must be completed by the prescriber or authorized personnel. INCOMPLETE FORMS WILL BE RETURNED.
Patient Name:
Patient DOB:
Patient ID #:
GlobalHealth ID numbers are 9 or 11 digits and start with 401, 411, or 601. If this request is for an ID number starting with 370, please
refer to the member’s ID card to determine whether to call Express Scripts at 800-935-6103 or CVS at 866-494-3927.
Prescriber’s Name: ____________________________________________________________________________________________
Collaborating physician (for PAs, NPs, etc.): ________________________________________________________________________
Contact person at prescriber’s office: ______________________________________________________________________________
Phone number: _______________________________________
Fax number: _______________________________________
Requested drug:
□Genotropin
□Norditropin NordiFlex
□Genotropin MiniQuick
□Nutropin AQ NuSpin 5*
□Humatrope
□Nutropin AQ NuSpin 10*
□Norditropin FlexPro
□Nutropin AQ NuSpin 20*
□Other: _________________________________________
□Nutropin AQ Pen*
□Omnitrope*
□Saizen*
□Saizen Click.Easy*
□Serostim
□Zomacton*
□Zorbtive
*These products are excluded from coverage except in documented cases of allergy or intolerance to ALL other comparable products.
GlobalHealth benefits require covered medications to be prescribed in adherence to FDA-approved and manufacturer-recommended
indications, strength, dosage, treatment duration, etc. Please refer to the requested product’s Prescribing Information, generally
available on the manufacturer’s website, for detailed product information.
1) What is the patient's diagnosis?
□Growth failure associated with:
□Growth failure in children
□chronic renal insufficiency
□Growth failure in adults, adult-onset
□Noonan syndrome
□Growth failure in adults, childhoodonset
□Prader-Willi syndrome
□Idiopathic short stature
□Turner syndrome
□Other (please provide related diagnosis code and description):
□Short bowel syndrome
□Short-stature homeobox-containing
gene deficiency
□Wasting or cachexia associated with
HIV
___________________________________________________________________________________________________________
1a) Please attach results of growth hormone stimulation tests, or explain why testing is not required or warranted for the patient’s
condition:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
1b) Please attach height & weight charts indicating patient's current stats and percentiles.
1c) Have pituitary tumors and other brain tumors been ruled out as a cause for the patient’s condition? .............. □Yes
□No
2) Provide the:
Prescribed dosage: ___________________________________________________________________________________________
Prescribed frequency: _________________________________________________________________________________________
Requested duration: __________________________________________________________________________________________
Last updated 3/4/2016
3) Does the patient have hypersensitivity to somatropin or any other component of the product; closed epiphyses; active proliferative,
preproliferative, or severe nonproliferative diabetic retinopathy; evidence of active malignancy; acute critical illness caus ed by
complications following open-heart or abdominal surgery or multiple accidental trauma; acute respiratory failure; sensitivity to
metacresol or glycerin; or any other known contraindication to this product?......................................................... □Yes
□No
If yes, please explain:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
4) Is the patient taking glucocorticoids, cytochrome P450-metabolized drugs, oral estrogen, insulin and/or other hypoglycemic agents,
or any other product known to interact with the requested product? ...................................................................... □Yes
□No
If yes, please list:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
5) A number of warnings and precautions are noted for this medication. Has the prescriber reviewed the patient medical history and
determined the potential clinical response reward to be greater than the risk to this medication therapy? ............ □Yes
□No
6) During the FDA approval process the manufacturer determined a number of patient monitoring requirements should be adopted f or
patients on this medication, including periodic thyroid function tests and glucose levels, monitoring of standard hormonal replacement
therapy, for malignant transformation of skin lesions, and for patients with a history of scoliosis. Will the prescriber adopt the recognized
monitoring requirements? ....................................................................................................................................... □Yes
7) Is the patient currently pregnant or breast-feeding? ........................................................................................... □Yes
□No
□No
8) Have you determined the patient’s willingness to be compliant with this therapy as well as your prescribed dosage, and do you feel
they can remain compliant during the course of this therapy?................................................................................ □Yes
9) Is the patient enrolled in a clinical study related to the requested therapy? ....................................................... □Yes
□No
□No
10) What is the goal and anticipated length of this therapy?
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
If the patient is an adult:
1) Can the patient’s growth hormone deficiency be attributed to pituitary disease, hypothalamic disease, surgery, radiation, or trauma?
............................................................................................................................................................................... □Yes
□No
If yes, please explain:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
I certify that this Prior Authorization Questionnaire is accurate and truthful to the best of my knowledge and does not contain any false,
fictitious, or fraudulent statements.
___________________________________________________________________________________________________________
Signature & Title
Date
Last updated 3/4/2016