Download NORDITROPIN (somatropin) For Pediatric

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