Prior Authorization Form
Growth Hormone
This fax machine is located in a secure location as required by HIPAA regulations.
Complete/review information, sign and date. Fax signed forms to CVS/Caremark at 1-888-836-0730. When conditions are met, we will authorize the coverage of Growth Hormone.
Drug Name
(specify drug)
Patient Information
Patient Name:
Patient ID:
Patient Group No.:
Patient DOB: Patient Phone: Prescribing Physician Physician Name: Physician Phone: Physician Fax: Physician Address:
City, State, Zip:
Diagnosis: ICD Code:
Please circle the appropriate answer for each question.
1. Does the patient have any of the following
contraindications or exclusions to the use of GH therapy:
Y N · An active malignancy or history of malignancy in the past 12 months · Active proliferative or severe non-proliferative diabetic retinopathy · An acute critical illness (not including neonatal hypoglycemia) · Concurrent use with Increlex
[If yes, then no further questions.]
2. Does the patient have HIV-associated wasting syndrome AND meet all of the following conditions:
Y N · On antiretroviral therapy
· Tried and had a suboptimal response to alternative therapies (e.g., dronabinol, megestrol, cyproheptadine, testosterone therapy)
· Ruled out alternative causes of wasting (e.g., inadequate caloric intake, testosterone deficiency, peripheral GH resistance)
[If no, then skip to question 6.]
3. Is the patient currently on somatropin through a CVS Caremark administered benefit?
[If yes, then skip to question 5.]
4. Has the patient received previous rounds of GH therapy? Y N [If no, then skip to question 46.]
5. Did the patient’s body mass index (BMI) improve or stabilize in response to somatropin therapy?
Y N [If yes, then skip to question 46.]
[If no, then no further questions.]
6. Does the patient have a diagnosis of short bowel syndrome (SBS) and meet the following criteria for approval:
Y N · Patient is receiving specialized nutritional support AND
· Patient has received less than 8 weeks of GH therapy (lifetime) for SBS [If yes, then skip to question 46.]
7. Is the patient using GH therapy for one of the following reasons:
Y N · Cerebral palsy
· Congenital adrenal hyperplasia · Cystic fibrosis
[If yes, then no further questions.]
8. Is the patient using GH therapy for one of the following reasons:
Y N
· In combination with leuprolide for children with growth failure and advancing puberty · Russell Silver syndrome
[If yes, then skip to question 46.]
9. Is GH therapy prescribed for a pediatric patient? Y N [If no, then skip to question 39.]
10. Is the patient currently undergoing treatment with GH therapy through the CVS Caremark benefit?
Y N [If yes, then skip to question 37.]
11. Does the patient have neonatal hypoglycemia AND meet all of the following conditions:
Y N
· Other causes of hypoglycemia have been ruled out or other treatments have been ineffective
· The patient has a pretreatment randomly assessed GH level less than 20 ng/mL [If yes, then skip to question 46.]
12. Does the patient meet the following conditions: Y N · The patient has open epiphyses
· The patient has been evaluated for other causes of growth failure [e.g., hypothyroidism, malignancy, chronic systemic disease, skeletal disorders, malnutrition, celiac disease]
[If no, then no further questions.]
[If no, then skip to question 20.]
14. Did the patient have a delayed bone age for chronological age prior to initiation of GH therapy?
Y N [If no, then no further questions.]
15. Is the patient less than 2.5 years of age AND meet the following criteria:
Y N · Has a pretreatment height of greater than 2 SD below the mean AND · A slow growth velocity
[If yes, then skip to question 17.]
16. Does the patient meet the following conditions for use of GH therapy in pediatric patients:
Y N
· Has a pretreatment 1-year height velocity greater than 2 SD below the mean OR a pretreatment height of greater than 2 SD below the mean plus a 1-year height velocity greater than 1 SD below the mean
[If no, then no further questions.]
17. Prior to initiation of GH therapy, has the patient failed 2 pharmacologic provocative tests (peak level below 10 ng/mL)?
Y N
[If yes, then skip to question 46.]
18. Does the patient have a pituitary or CNS disorder (e.g., pituitary resection, blunt trauma to pituitary gland, CNS tumors, CNS malformation, CNS irradiation, multiple pituitary hormone deficiencies, or panhypopituitarism)?
Y N
[If no, then no further questions.]
19. Does the patient have a pretreatment IGF-1/IGFBP3 level greater than 2 SD below the mean?
Y N [If yes, then skip to question 46.]
[If no, then no further questions.]
20. Does the patient have the diagnosis of Turner syndrome confirmed by karyotyping AND is the patient 2 years of age or older?
Y N
[If no, then skip to question 23.]
21. Is the patient between the ages of 2 and less than 2.5 years old AND meet the following criteria?
Y N · Has a pretreatment height of greater than 2 SD below the mean AND · A slow growth velocity
[If yes, then skip to question 46.]
22. Does the patient meet the following criteria: Y N
· Has a pretreatment 1-year height velocity greater than 2 SD below the mean OR a pretreatment height of greater than 2 SD below the mean plus a 1-year height velocity greater than 1 SD below the mean
[If yes, then skip to question 46.] [If no, then no further questions.]
23. Does the patient have a diagnosis of Noonan syndrome? Y N [If no, then skip to question 25.]
24. Does the patient meet all of the following conditions: Y N · Is 3 years of age or older
· Has a pretreatment 1-year height velocity greater than 2 SD below the mean OR a pretreatment height of greater than 2 SD below the mean plus a 1-year height velocity greater than 1 SD below the mean
[If yes, then skip to question 46.] [If no, then no further questions.]
25. Does the patient have a diagnosis of chronic renal insufficiency?
Y N [If no, then skip to question 29.]
26. Does the patient meet all of the following conditions: Y N
· Metabolic, endocrine, and nutritional abnormalities have been treated or stabilized · Patient has not had a kidney transplant
[If no, then no further questions.]
27. Is the patient less than 2.5 years of age and meet the following criteria:
Y N · Has a pretreatment height of greater than 2 SD below the mean AND · A slow growth velocity
[If yes, then skip to question 46.]
28. Does the patient meet all of the following conditions: Y N
· Has a pretreatment 1-year height velocity greater than 2 SD below the mean OR a pretreatment height of greater than 2 SD below the mean plus a 1-year height velocity greater than 1 SD below the mean
[If yes, then skip to question 46.] [If no, then no further questions.]
29. Does the patient have a diagnosis of small for gestational age (SGA)?
Y N [If no, then skip to question 31.]
30. Does the patient meet all of the following conditions: Y N · Is 2 years of age or older
· Has a birth weight less than 2500 g at gestational age of greater than 37 weeks OR a birth weight or length less than 3rd percentile for gestational age
· Has failed to manifest catch-up growth by age 2 [If yes, then skip to question 46.]
[If no, then no further questions.]
31. Does the patient have the diagnosis of Prader-Willi Syndrome?
Y N [If no, then skip to question 35.]
· Ruled out upper airway obstruction via appropriate testing or examination
· GH therapy will be discontinued if patient develops severe respiratory impairment while on therapy
[If no, then no further questions.]
33. Is the patient less than 2.5 years of age and meet the following criteria:
Y N · Has a pretreatment height of less than 2 SD below the mean AND · A slow growth velocity
[If yes, then skip to question 46.]
34. Does the patient meet all of the following conditions: Y N
· Has a pretreatment 1-year height velocity less than 2 SD below the mean OR a pretreatment height of greater than 2 SD below the mean plus a 1-year height velocity greater than 1 SD below the mean
[If yes, then skip to question 46.] [If no, then no further questions.]
35. Does the patient have a diagnosis of SHOX (short stature homeobox-containing gene) deficiency confirmed by molecular or genetic testing analyses?
Y N
[If no, then no further questions.]
36. Does the patient meet all of the following conditions: Y N · Is 3 years of age or older
· Has a pretreatment 1-year height velocity greater than 2 SD below the mean OR a pretreatment height of greater than 2 SD below the mean plus a 1-year height velocity greater than 1 SD below the mean
[If yes, then skip to question 46.] [If no, then no further questions.]
37. Does the patient have neonatal hypoglycemia AND meet the following criteria for continuation of therapy:
Y N
· Patient is euglycemic or the patient’s therapy will be adjusted to optimize therapy [If yes, skip to question 46.]
38. Does the patient meet all of the following conditions for continuation of GH therapy:
Y N · The patient is growing greater than 2 cm/year
· The patient has open epiphyses
· For Prader-Willi syndrome only: body composition has improved [If yes, then skip to question 46.]
[If no, then no further questions.]
39. Does the patient have a diagnosis of adult GHD? Y N [If no, then no further questions.]
40. Is the patient currently undergoing treatment with GH therapy through the CVS Caremark benefit?
Y N [If yes, then skip to question 45.]
41. Has the patient been assessed for other causes of GHD-like symptoms (e.g., hypothyroidism, malignancy, chronic systemic disease)?
Y N
[If no, then no further questions.]
42. Prior to initiation of therapy, has the patient failed at least two pharmacologic provocative tests with peak level less than 5 µg/L?
Y N
[If yes, then skip to question 46.]
43. Does the patient have one of the following: Y N
· Greater than or equal to 3 pituitary hormone deficiencies (includes panhypopituitarism) OR
· Patient had childhood-onset GHD with known mutations, embryopathic lesions, or irreversible structural lesions/damage
[If yes, then skip to question 46.]
44. Does the patient meet all of the following conditions for use of GH therapy in an adult:
Y N · Has a documented low pretreatment IGF-1 level
· Has failed 1 pharmacologic provocative test prior to initiation of GH therapy with peak levels less than 5 µg/L?
[If yes, then skip to question 46.] [If no, then no further questions.]
45. Will the patient’s serum insulin-like growth factor 1 (IGF-1) be evaluated to confirm the appropriateness of continued therapy?
Y N
[If no, then no further questions.]
46. Is the GH therapy being prescribed by or in consultation with one of the following specialists:
Y N · endocrinologist
· gastroenterologist/nutritional support specialist (SBS) · pediatric nephrologist (CRI)
· infectious disease specialist (HIV wasting) Comments:
I affirm that the information given on this form is true and accurate as of this date.