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NORDITROPIN (somatropin) For Pediatric Growth Hormone Deficiency and Growth Failure Secondary to Chronic Renal Failure/Insufficiency in Children who have not received a Renal Transplant PRIOR AUTHORIZATION FORM Please complete and fax all requested information below including any progress notes, laboratory test results, or chart documentation as applicable to Gateway HealthSM Pharmacy Services. FAX: (888) 245-2049 If needed, you may call to speak to a Pharmacy Services Representative. PHONE:(800) 528-6738 Monday through Friday 8:30am to 4:30pm PROVIDER INFORMATION Requesting Physician: Physician Specialty: Office Address: NPI: Office Contact: Office Phone: Office Fax: MEMBER INFORMATION Patient Name: Gateway ID: DOB: DRUG INFORMATION Medication: Strength: Frequency: Duration: MEDICAL HISTORY (Attach Documentation including progress notes, laboratory values, and growth charts) Diagnosis (Fax all relevant tests results and progress notes with this form): Pediatric Growth Hormone Deficiency Growth Failure Secondary to Chronic Renal Failure/Insufficiency in children who have not received a renal transplant Other: ______________________________________________________________________ Was a wrist film evaluation completed to determine if epiphyses are confirmed as open (Attach results)? Yes No Was an X-ray of left wrist or hand completed to determine skeletal maturation? Yes No Please provide the standard deviations from the mean for age and gender: ________________________________ Current Height: ___________ Date: ___________ Previous Height: ____________ Date: _______________ Please provide the following and attach growth chart: Patient’s Height Percentile on growth chart: _________________________________________________________ Patient’s Growth Velocity and associated standard deviations from the mean: _____________________________ Patient’s Growth over the last year: ________________________centimeters___________________________ Provide results of two stimulation tests (Attach results separately) Two Stimulation Test Results: 1. Result: ___________ Agent Used: ____________ Date:_____________ 2. Result: ___________ Agent Used: _____________ Date: ______________ Provide results of IGF-1 and IGFBP-3 and list the standard deviations below the mean for age and sex: IGF-1: _____________ Standard Deviation: _______________ Date: ______________________ IGFBP-3: ___________ Standard Deviation: ______________ Date: _______________________ REAUTHORIZATION CRITERIA Please provide the patient’s growth in centimeters over the last year: ______________________cm Include most recent growth chart, labs, and progress notes Has the patient entered puberty? Yes No Prescribing Physician Signature Date NORDITROPIN (somatropin) For Growth Failure in Children Small for Gestational Age (SGA) PRIOR AUTHORIZATION FORM Please complete and fax all requested information below including any progress notes, laboratory test results, or chart documentation as applicable to Gateway HealthSM Pharmacy Services. FAX: (412) 255-4544 or (888) 245-2049 If needed, you may call to speak to a Pharmacy Services Representative. PHONE:(800) 528-6738 Monday through Friday 8:30am to 4:30pm PROVIDER INFORMATION Requesting Physician: Physician Specialty: Office Address: NPI: Office Contact: Office Phone: Office Fax: MEMBER INFORMATION Patient Name: Gateway ID: DOB: DRUG INFORMATION Strength: Duration: MEDICAL HISTORY (Attach Documentation including progress notes, laboratory values, and growth charts) Medication: Frequency: Diagnosis (Fax all relevant tests results and progress notes with this form): Growth Failure in Children Small for Gestational Age (SGA) Other: ______________________________________________________________________________________ Current Height: _______________ Date: ________________ Previous Height: _______________ Date: _________________ At birth, did the patient have: Weight < 2500 gm at gestational age > 37 weeks Weight or length below the 3rd percentile for gestational age Did the patient achieve catch up growth in length by age 2? Yes No If Yes, has the catch up growth stopped? Yes No Was a wrist film evaluation completed to determine if epiphyses are confirmed as open (Attach results)? Yes No Has the patient entered puberty? Yes No SUPPORTING INFORMATION AND CLINICAL RATIONALE REAUTHORIZATION CRITERIA What was the patient’s growth in centimeters over the past year? ______________________ cm Prescribing Physician Signature Date NORDITROPIN (somatropin) For Gonadal Dysgenesis (Turner Syndrome) PRIOR AUTHORIZATION FORM Please complete and fax all requested information below including any progress notes, laboratory test results, or chart documentation as applicable to Gateway HealthSM Pharmacy Services. FAX: (412) 255-4544 or (888) 245-2049 If needed, you may call to speak to a Pharmacy Services Representative. PHONE:(800) 528-6738 Monday through Friday 8:30am to 4:30pm PROVIDER INFORMATION Requesting Physician: Physician Specialty: Office Address: NPI: Office Contact: Office Phone: Office Fax: MEMBER INFORMATION Patient Name: Gateway ID: DOB: DRUG INFORMATION Strength: Duration: MEDICAL HISTORY (Attach Documentation including progress notes, laboratory values, and growth charts) Medication: Frequency: Diagnosis (Attach to fax all relevant tests results and progress notes with this form): Turner Syndrome (Provide confirmation of the diagnosis) Other: _____________________________________________________________________________________ Current Height: ___________ Date Taken: ________________ Previous Height: ___________ Date Taken: ________________ Was a wrist film evaluation completed to determine if epiphyses are confirmed as open (Attach results)? Yes No Has the patient entered puberty? Yes No SUPPORTING INFORMATION or CLINICAL RATIONALE REAUTHORIZATION CRITERIA What was the patient’s growth in centimeters over the past year? ______________________ cm Has the patient entered puberty? Yes No Please describe the clinical benefit of the use of Norditropin in this patient: Prescribing Physician Signature Date NORDITROPIN (somatropin) For Treatment of Prader-Willi Syndrome PRIOR AUTHORIZATION FORM Please complete and fax all requested information below including any progress notes, laboratory test results, or chart documentation as applicable to Gateway HealthSM Pharmacy Services. FAX: (412) 255-4544 or (888) 245-2049 If needed, you may call to speak to a Pharmacy Services Representative. PHONE:(800) 528-6738 Monday through Friday 8:30am to 4:30pm PROVIDER INFORMATION Requesting Physician: Physician Specialty: Office Address: NPI: Office Contact: Office Phone: Office Fax: MEMBER INFORMATION Patient Name: Gateway ID: DOB: DRUG INFORMATION Strength: Duration: MEDICAL HISTORY (Attach Documentation including progress notes, laboratory values, and growth charts) Medication: Frequency: Diagnosis Prader-Willi Syndrome Other: _____________________________________________________________________________________ Was a sleep study conducted? Yes, Please attach results No Does the sleep study results show obstructive sleep apnea diagnosis? Yes No Has the patient had a tonsillectomy and/or an adenoidectomy? Yes No Does the patient still have obstructive sleep apnea? Yes No Is the patient on CPAP or biPAP? Yes No Have you discussed and documented the risks associated with growth hormone use in a patient with sleep apnea? Yes (Please provide documentation in progress notes) No Current Height: _____________ Date: _______________ Previous Height: _____________ Date: ___________ SUPPORTING INFORMATION or CLINICAL RATIONALE REAUTHORIZATION CRITERIA Has the patient had a repeat sleep study in the past six months? Yes (Please attach) No Did the sleep study document sleep apnea? Yes No If the patient still has sleep apnea, is it being treated and/or is it being monitored while on growth hormone? Yes No Has treatment with growth hormone resulted in an increase in growth, tone, and/or weight loss? Yes (Please attach evidence in progress notes) No Prescribing Physician Signature Date NORDITROPIN (somatropin) For Adult Growth Hormone Deficiency Syndrome PRIOR AUTHORIZATION FORM Please complete and fax all requested information below including any progress notes, laboratory test results, or chart documentation as applicable to Gateway HealthSM Pharmacy Services. FAX: (412) 255-4544 or (888) 245-2049 If needed, you may call to speak to a Pharmacy Services Representative. PHONE:(800) 528-6738 Monday through Friday 8:30am to 4:30pm PROVIDER INFORMATION Requesting Physician: Physician Specialty: Office Address: NPI: Office Contact: Office Phone: Office Fax: MEMBER INFORMATION Patient Name: Gateway ID: DOB: DRUG INFORMATION Medication: Strength: Frequency: Duration: MEDICAL HISTORY (Attach Documentation including progress notes, laboratory values, and growth charts) Diagnosis New request for Adult Growth Hormone Deficiency Transition of treatment with growth hormone from a child to an adult Other: ______________________________________________________________________________________ Is the adult growth hormone deficiency a result of pituitary or hypothalamic disease, surgery, radiation therapy, or trauma? (Provide chart documentation including MRI and other relevant test results) Yes No Did the patient have childhood onset growth hormone? Yes No Provide results of two growth hormone stimulation tests (Provide test results separately) Two Stimulation Test Results: ___________ ____________ Date Taken: ____________________ If the patient is transitioning with treatment from a child to an adult, has the patient had a washout period of one month of growth hormone? Yes No Provide laboratory tests results of the IGF-1: ________________ Date Taken: ___________________________ SUPPORTING INFORMATION or CLINICAL RATIONALE REAUTHORIZATION CRITERIA Has treatment with growth hormone resulted in clinical benefit (increase in total lean body mass, exercise capacity, improved lipid profile, improvement of fatty live, enhanced mood)? Yes, please provide evidence in chart documentation No Provide laboratory tests results of the IGF-1: ________________ Date Taken: ___________________________ Prescribing Physician Signature Date NORDITROPIN (somatropin) For Noonan’s Syndrome PRIOR AUTHORIZATION FORM Please complete and fax all requested information below including any progress notes, laboratory test results, or chart documentation as applicable to Gateway HealthSM Pharmacy Services. FAX: (412) 255-4544 or (888) 245-2049 If needed, you may call to speak to a Pharmacy Services Representative. PHONE:(800) 528-6738 Monday through Friday 8:30am to 4:30pm PROVIDER INFORMATION Requesting Physician: Physician Specialty: Office Address: NPI: Office Contact: Office Phone: Office Fax: MEMBER INFORMATION Patient Name: Gateway ID: DOB: DRUG INFORMATION Medication: Strength: Frequency: Duration: MEDICAL HISTORY (Attach Documentation including progress notes, laboratory values, and growth charts) Diagnosis Noonan’s Syndrome Other, Please specify: __________________________________________________________________________ Current Height: ___________ Date: ___________ Previous Height: _________ Date: ________________ Is the patient’s height less than 2 standard deviations below average for the population mean height for age and sex AND the height velocity measures over 1 year is greater than 1 standard deviation below the mean for chronological age? Yes, Provide evidence through progress notes and growth charts No Has there been a cardiology consult with results of an echocardiogram to determine if there is an underlying cardiac defect? Yes, provide evidence through consultation note and ECG results No Has the physician documented discussions with the patient’s parents regarding the risk of growth hormone use if the member has cardiac features such as stenotic pulmonic valves, congenital heart defects, or hypertrophic cardiomyopathy? Yes, Provide evidence through progress notes No SUPPORTING INFORMATION or CLINICAL RATIONALE REAUTHORIZATION CRITERIA Does the physician continue to monitor any cardiac defects while on growth hormone? (Provide follow up cardiac evaluations necessary even if the patient has no underlying cardiac disease to evaluate changes the could evolve with growth hormone therapy) Yes No Prescribing Physician Signature Date