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Prior Authorization Form
Growth Hormones
Access this PA form at https://tenncare.magellanhealth.com/static/docs/Prior_Authorization_Forms/TennCare_Growth_Hormone_PA_Form.pdf
If the following information is not complete, correct, or legible, the PA process can be delayed. Use one form per member please.
Member Information
LAST NAME:
FIRST NAME:
ID NUMBER:
DATE OF BIRTH:
–
–
Prescriber Information
LAST NAME:
FIRST NAME:
NPI NUMBER:
DEA NUMBER:
PHONE NUMBER:
FAX NUMBER:
–
–
–
Is the prescriber a TennCare provider with a Medicaid ID?
Yes
No
Is the prescriber a single-patient contract holder for this patient?
Yes
No
–
REQUESTED AGENT
Preferred
Non-Preferred
Genotropin®
SPECIFY: _______________________
DRUG STRENGTH:
DIRECTIONS:
****Do not include documentation that is not requested on this form****
Clinical Criteria Documentation
1.
Please select the indication(s) for which growth hormone is being used:
Growth hormone deficiency
Small for Gestational Age (SGA)
Hypothalamic-pituitary disease, or structural lesions or trauma to the pituitary
(including pituitary tumor, pituitary surgical damage, trauma, and cranial irradiation)
Idiopathic Short Stature
Short stature associated with Turner’s Syndrome
Cachexia or AIDS wasting
Short stature associated with Noonan Syndrome
Short bowel syndrome
Prader-Willi Syndrome
Short Stature Homeobox (SHOX) gene
Chronic renal insufficiency
Other (please describe):
Intrauterine Growth Retardation (IGR)
2.
Has the recipient tried the preferred agent, Genotropin®, in the past?
LENGTH OF TRIAL:
3.
Yes (complete below)
No
REASON FOR DISCONTINUATION:
Has the recipient undergone growth hormone stimulation testing?
GH < 5 ng/mL
GH 5-10 ng/mL
Yes (complete below)
GH > 10 ng/mL
No
Not performed
GH < 5 ng/mL
GH Stimulation Test 1
GH Stimulation Test 2
4.
Has a test measuring the level of insulin-like growth factor 1 (IGF-1) been performed for this recipient?
If yes, was the IGF-1 level below the normal range for the recipient’s age?
Yes
No
Continued on next page. Signature MUST be submitted on page 2.
This facsimile transmission contains legally privileged and confidential information intended for the parties identified below.
If you have received this transmission in error, please immediately notify us by telephone and return the original message to
TennCare Pharmacy Program, c/o Magellan Health Services, 1st Floor South, 14100 Magellan Plaza, Maryland Heights, MO 63043.
Distribution, reproduction or any other use of this transmission by any party other than the intended recipient is strictly prohibited.
© 2016, Magellan Health Services. All Rights Reserved.
Revision Date: 07/01/2016
Yes
No
Prior Authorization Form
Growth Hormones
Access this PA form at https://tenncare.magellanhealth.com/static/docs/Prior_Authorization_Forms/TennCare_Growth_Hormone_PA_Form.pdf
PATIENT NAME:
DATE OF BIRTH:
–
5.
6.
–
Please indicate any hormone deficiencies identified in this recipient (check all that apply):
Thyroid stimulating hormone (TSH)
Follicle stimulating hormone (FSH)
Luteinizing hormone (LH)
Adrenocorticotropic hormone (ACTH)
Prolactin
None of the above
If the request is for a recipient under 21 years of age, please answer the following questions:
What is the recipient’s current height?
How many standard deviations (SDs) below the population mean is this height for the recipient’s age?
Have the recipient’s epiphyses closed (fused)?
Is the recipient’s height velocity within the normal range for the patient’s age or bone age?
7.
<2
Yes
Yes
≥2
No
No
Yes
No
Yes
Yes
No
No
If the request is for a newborn infant, please answer the following questions:
Has the infant exhibited signs of hypoglycemia?
Indicate recorded GH level:
Yes
Has a growth hormone level been obtained for recipient?
Has an IGF-1 / IGF Binding Protein #3 level been obtained for the recipient?
If yes, was the level low for the patient’s age?
No
Please note any other information pertinent to this PA request:
Prescriber Signature (Required)
Date
(By signature, the Physician confirms the above information is accurate and verifiable by patient records.)
Fax This Form to: 1-866-434-5523
Mail requests to: TennCare Pharmacy Program
c/o Magellan Health Services
1st floor South, 14100 Magellan Plaza
Maryland Heights, MO 63043
Phone: 1-866-434-5524
Magellan Health Services will provide a response within 24 hours upon receipt.
© 2016, Magellan Health Services. All Rights Reserved.
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