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Anthem Blue Cross and Blue Shield State Sponsored Business Growth Hormone EnrollmentForm Fax completed form to: 1-866-545-0062. You may reach provider services at 1-888-662-0944. Part I Patient Information (double click on the fields below to fill in this form electronically) Patient’s last name First name Middle initial Address Day phone no. ( City ) Night phone no. ( - Parent/Guardian ) Sex Primary insurance Secondary insurance Cardholder name (if not patient) Cardholder name (if not patient) BIN# Insurance phone no. (+area code) ( ) ZIP code Date of birth - Allergies Member ID and Group no. State M / F Member ID and Group no. BIN# Insurance phone no. (+area code) ( - Employer / ) - Employer Part II Physician Information (please supply copy of patient’s insurance card) Prescriber’s name Hospital/Clinic Office contact name Address Phone no. (+area code) ( City ) - Fax no. (+area code) ( ) DEA no. - State ZIP code NPI no. UPIN Part III Medical Criteria (double click on the fields below to fill in this form electronically) 1. HEIGHT AND WEIGHT Height: in cm Date Taken: / / Weight: lb kg Date Taken: / / 2. PRIMARY DIAGNOSIS Adult Pediatric (* = fill out additional items in Section 4) 042 HIV with AIDS Wasting* 225 Benign Neoplasm of the brain/CNS 253 Pituitary Disorders/hypothalamic control 579.3 Post-Surgical Nonabsorption (Short Bowel Syndrome) 585 Chronic Renal Insufficiency* 588 Renal Osteodystrophy 758.6 Gonadal dysgenesis (Turner’s syndrome) 765.2 Child born small for gestational age* 759.81 Prader-Willi Syndrome* 759.89 Other unspecified anomalies (Noonan’s) 764 Fetal Growth Retardation, unspecified 783.43 Idiopathic short stature 799.4 Cachexia 990 Effects of radiation, unspecified Other (ICD-9 Required) __________________________________ 3. CLINICAL INFORMATION 1. How many standard deviations below the mean is this patient for final adult skeletal age? (delayed bone age) _______________ 2. What growth velocity percentile (measured at least over 2 years) does this patient fall under? _______________ 3. How many standard deviations (SD) below the mean is this patient for final adult height? (If unknown, see question #4 below) _______________ 4. If the above question #3 is unknown, what growth percentile for age does this patient fall under? _______________ 4. DISEASE SPECIFIC INFORMATION (Please complete applicable sections.) Prader-Willi Syndrome: Does the patient have any of the following risk factors? (Check all that apply) Severe Obesity Sleep apnea History of Respiratory Impairment Unidentified Respiratory Infection Other: _______________ AIDS Wasting Syndrome: 1. What baseline percentage weight loss, attributed to HIV infection, has this patient experienced? % 2. Is the patient currently being treated with antiviral therapy? Yes No Small for Gestational Age (SGA): 1. How many standard deviations (SD) below the mean is this patient for their age for the following parameters: Length/Height: _______________ Weight: _______________ 2. Are there any other factors that may contribute to the shortness of stature such as growth inhibiting medications, chronic diseases, endocrine disorders, emotional deprivation or syndromes? (List and provide growth curves): _____________________ For growth failure associated with GHD, CRI and End Stage Renal Disease: 1. Bone Age: _______________ Date: / / 2. Chronological Age: Growth Velocity: IGF-1 Results: 3. Has the patient undergone pituitary surgery or radiation therapy? Yes No 4. Please indicate what Growth Hormone Stimulation tests have been performed: (Check all that apply) Arginine Glucagons Clonidine L-dopa Propranolol Insulin induced hypoglycemia Other: _______________ 5. List and attach a copy of Growth Hormone Stimulation Test Results and Reagents Used Results: _______________________ Results: _______________________ Results: _______________________ Results: _______________________ 6. Please list any other documented pituitary hormone deficiencies. _______________________ _______________________ _______________________ _______________________ This is Page 1 of 2. Please complete all pages before faxing to us. *Confidentiality notice: This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reliance on the contents of this document is strictly prohibited www.anthem.com Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 1109 INW2390 11/17/09 Patient First Name: ____________________________ Patient Last Name: ____________________________ DOB: / / Part IV Prescription (double click on the fields below to fill in this form electronically) Preferred products are Humatrope®, Nutropin®, and Nutropin AQ®. 1. MEDICATION Humatrope® 6 mg cartridge 12 mg cartridge 24 mg cartridge 5 mg vial Nutropin® 5 mg vial 10 mg vial Nutropin AQ® 10 mg cartridge 20 mg cartridge 10 mg vial Other drug: (Must complete Section 5 Prior Therapies) _________________________________________________________ _________________________________________________________ 2. DOSING INTRUCTIONS Inject mg subcutaneously Dilute with mL of diluent Daily OR Injection volume days per week mL Other specific dosing instructions: _________________________________________________________ _________________________________________________________ Quantity: Refills: 28 day supply 84 day supply 1 year Other: 3. SUPPLIES Pens: One (1) HumatroPen® 6 mg One (1) HumatroPen® 12 mg One (1) HumatroPen® 24 mg One (1) Nutropin AQ Pen 10® One (1) Nutropin AQ Pen 20® Needles and Syringes: BD 31G 8mm short pen needles Novofine® 30G 8 mm pen needles BD 1cc 31G 5/16” insulin syringes BD 1/2cc 31G 5/16” insulin syringes Other: Supply: Supply: Prescriber’s signature Other: 4. INJECTION TRAINING Will injection training be coordinated by presriber’s office? Does patient require pharmacy to coordinate injection training with a skilled nurse? Yes Yes No No 5. PRIOR THERAPIES Non-preferred HGH agents require a trial of Humatrope AND Nutropin AND/OR Nutropin AQ within the previous 6 month for new starts unless non-formulary agent has FDA approved indication that is not approved for the formulary agent(s). Check applicable boxes: 1. Patient is a new user of requested medication Yes No 2. Patient has tried the preferred HGH within the previous 6 months Yes No 3. Patient is currently established on requested medication Yes No 6. ANNUAL MEDICAL REVIEW Review for medical necessity for children should occur annually: Result of the 1st year of therapy: Yes No Has there been a doubling of the pre-treatment growth rate? Yes No Has there been an increase in pre-treatment growth rate of 3cm/year or more? For therapy continuing past the first year: Yes No Has the growth rate remained above 2.5 cm/year? For children over 12 years of age: Yes No Has there been an x-ray report that shows that the epiphyses have not yet closed? Quantity: Quantity: Quantity: Quantity: Quantity: Quantity: Date / / Ship medication to: Need by Date: / Patient Home Physician Office Other / If shipping to Physician, office must be available to receive shipment on this date. This is page 2 of 2. Please complete page 1 before faxing to PrecisionRx Specialty Solutions. *Confidentiality notice: This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reliance on the contents of this document is strictly prohibited