Currentblue cross blue shield - kansasPolicy N/A

Growth Hormone Prior Authorization Request

A prior authorization request form and instructions for growth hormone therapy for BCBS Kansas members, detailing required documentation, clinical information for initial and renewal requests, and administrative submission instructions. It specifies required tests (growth hormone stimulation testing), documentation of diagnosis and growth data, and requirement to trial preferred product.

Policy Summary

Payerblue cross blue shield - kansas

PolicyGrowth Hormone Prior Authorization Request

Policy CodePolicy N/A

Change TypeAdministrative form / coverage with criteria

Effective Date

Next Review Date

Key ActionPrescriber must complete and sign the Growth Hormone Prior Authorization Request form and attach required documentation and submit via fax, email, or mail to BCBSKS Prior Authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — brief indicates this is a prior authorization form and instructions; has_material_change=false.

1Preferred product trial required

Adults:1/Children:2GH stimulation tests

Labs/Imaging/ChartsDocumentation required

Coverage Summary

This is the BCBSKS Growth Hormone Prior Authorization Request form (physician fax form). Coverage is covered with criteria and requires submission of the completed prescriber form and all required documentation. Required tests include growth hormone stimulation testing ( Adults: 1 stim test; Children: 2 stim tests). Approval also requires trial and failure of the BCBSKS Preferred Product before coverage of a non-preferred growth hormone.

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Prior Authorization Requirements & Clinical Criteria

General Prior Authorization Requirements

Approval requires submission of all required documentation and trial/failure of preferred agent when applicable.

Prescriber section: Completed prescriber section (only prescriber may complete form) including prescriber name, specialty, NPI, signature, and contact information
Source: Section 2 and header note
Patient demographics and insurance: Patient demographic and insurance information including copy of front/back of insurance card if possible
Source: Section 1
Product selection and preferred agent trial: Specify product: BCBSKS Preferred Product or Other Growth Hormone; approval requires trial and failure of the preferred agent if Other Growth Hormone is requested
Source: Section 1
Indicate renewal status: Indicate whether request is renewal and if renewal provide date therapy started
Source: Section 1
Rx order details: Provide Rx order details: form, strength/dose, quantity, refills, directions/frequency, ancillary supplies needed per injection; indicate pharmacy (Accredo or other)
Source: Section 1 and Section 2
Attachments - chart information: Attach relevant chart information (growth curves, imaging studies, stim tests, growth charts)
Source: Section 2
Open epiphyses: For children: document open epiphyses status (Yes/No)
Source: Section 2
Complicating factors: Document presence and treatment status of complicating factors (including malnutrition and acidosis) and whether treated if present
Source: Section 2
Childhood-onset confirmation: Document whether childhood-onset GHD was confirmed by testing during childhood (Yes/No)
Source: Section 2
Imaging: Document imaging demonstrating hypothalamic or pituitary disease/injury if applicable (Yes/No)
Source: Section 2
Growth and bone age data: Provide bone age, date measured, patient age when measured, height at diagnosis (cm), percentile of normal height, mid-parental height, growth rate (cm/yr) at diagnosis, and current growth rate for renewals
Source: Section 2
Laboratory results for adults: Attach copies of relevant laboratory results (IGF-1, TSH, FSH/LH, ACTH) for adults as applicable
Source: Section 5
Growth hormone stimulation testing required: one stim test for adults; two stim tests for children. Attach stim test results including agents used and peak valuesAdults: 1 stim test; Children: 2 stim tests
Source: Section 5

Renewal Criteria

Renewal requests must demonstrate ongoing benefit and maintenance of improvement.

Renewal identification and therapy start date: Indicate renewal and date therapy started
Source: Section 2
Demonstrated clinical improvement: Demonstrate that growth hormone therapy resulted in demonstrated clinical improvement since initiation of therapy
Source: Section 2
Maintenance of improvement: If improvement occurred, indicate whether improvement has continued for or been maintained for one year or longer>=1 year if maintained
Source: Section 2

Provider Actions & Submission Instructions

Prior Authorization

Submit completed prior authorization form

Prescriber must complete and sign the Growth Hormone Prior Authorization Request form and attach required documentation (labs, stim test results, growth charts, imaging, insurance card copies) and submit via fax, email, or mail to Blue Cross and Blue Shield of Kansas Prior Authorization.

Only the prescriber may complete and sign the form
Attach supporting documentation: labs, stimulation test results, growth charts, imaging, copy of front/back of insurance card
Submit completed form via Fax, Email, or Mail to BCBSKS Prior Authorization

Documentation Required

Attach stimulation test results

Attach growth hormone stimulation test results. Adults require one stimulation test; children require two. Include the agents used and the peak values for each test.

Adults: 1 stimulation test required
Children: 2 stimulation tests required
Include agent(s) used and peak values for each test

Documentation Required

Attach lab and growth documentation

Attach relevant laboratory and growth documentation. For adults include IGF-1, TSH, FSH/LH, ACTH lab results. Include growth curves, bone age (with date and patient age when measured), height at diagnosis (cm), percentiles, mid-parental height, and growth rate information.

Attach lab results: IGF-1, TSH, FSH/LH, ACTH (adults)
Include growth curves and bone age with date and patient age when measured
Provide height at diagnosis (cm), percentile of normal height, mid-parental height, growth rate (cm/yr) at diagnosis, and current growth rate for renewals

Step Therapy

Preferred product trial required

Approval requires a trial and documented failure of the BCBSKS preferred growth hormone agent before coverage will be provided for a non-preferred growth hormone.

Indicate product selection: BCBSKS Preferred Product or Other Growth Hormone
Note: Approval requires trial and failure of the preferred agent

Billing Rule

Pharmacy designation

Specify the pharmacy to be used: select the preferred pharmacy (Accredo) or Other and include pharmacy contact information when indicated.

Preferred pharmacy: Accredo — Phone: 833-721-1620, Fax: 888-302-1028
Or indicate Other pharmacy and provide contact details

Background

This document is a faxable prior authorization form used to request coverage for growth hormone therapy. Only the prescriber may complete the form. Administrative and clinical documentation required for initial and renewal requests must be attached, including patient demographics, copy of front/back of insurance card when possible, prescriber information and signature, the Rx/order details, and designation of pharmacy (Accredo or other).

Clinical documentation required includes growth charts/curves, imaging studies, bone age and associated dates, height and percentile information, mid-parental height, growth rates, and relevant laboratory tests (IGF-1, TSH, FSH/LH, ACTH) for adults. Growth hormone stimulation testing is required for all patients—attach stim test results listing agents used and peak values: Adults: 1 stim test; Children: 2 stim tests.

Renewal requests must indicate the date therapy started and demonstrate clinical improvement since initiation; if improvement occurred, indicate whether improvement has been maintained for one year or longer and provide current growth rate. The form also asks about open epiphyses status and whether complicating factors (eg, malnutrition, acidosis) are present and treated.

Submit the completed form and attachments via fax, email, or mail to Blue Cross and Blue Shield of Kansas Prior Authorization as listed on the form.

Open epiphyses: clinical status indicating growth plates are not yet closed (form asks Yes/No).

OpenPayer

Growth Hormone Prior Authorization Request

Coverage Summary

Prior Authorization Requirements & Clinical Criteria

Provider Actions & Submission Instructions

Background

Coding

Revision History