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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
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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