State Sponsored Business, UniCare Health Plan of Kansas, Inc.
Growth Hormone Enrollment Form
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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 / City / State / ZIP code
Day phone no. () - / Night phone no. () - / Date of birth //
Parent/Guardian / Allergies / Sex M F
Primary insurance / Secondary insurance
Cardholder name (if not patient) / Cardholder name (if not patient)
Member ID and Group no. / BIN# / Member ID and Group no. / BIN#
Insurance phone no. (+area code) () - / 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 / City / State / ZIP code
Phone no. (+area code) () - / Fax no. (+area code) () - / DEA no. / 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.
______
______
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® Nutropin® Nutropin AQ®
6 mg cartridge 5 mg vial 10 mg cartridge
12 mg cartridge 10 mg vial 20 mg cartridge
24 mg cartridge 10 mg vial
5 mg vial
Other drug: (Must complete Section 5 Prior Therapies)
______
______
2. DOSING INTRUCTIONS
Inject mg subcutaneously Daily OR days per week
Dilute with mL of diluent Injection volume mL
Other specific dosing instructions: ______
______
Quantity: 28 day supply 84 day supply Other:
Refills: 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 Quantity:
Novofine® 30G 8 mm pen needles Quantity:
BD 1cc 31G 5/16” insulin syringes Quantity:
BD 1/2cc 31G 5/16” insulin syringes Quantity:
Other:
Supply: Quantity:
Supply: Quantity: / 4. INJECTION TRAINING
Will injection training be coordinated by presriber’s office? Yes No
Does patient require pharmacy to coordinate injection training with a Yes No
skilled nurse?
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?
Prescriber’s signature / Date // / Ship medication to: Patient Home Physician Office Other
Need by Date: / / 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 CuraScript.
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