NYS Medicaid Pharmacy Prior Authorization Programs
Prior Authorization Call Line: 1-877-309-9493
Prior authorization for somatropin (Serostim®) is required to assure medical necessity and to deter the potential of, or history of, drug diversion or illegal utilization. Only prescribers, not their authorized agents, can initiate the prior authorization process for Serostim®.
Prior authorization requirements:
- Prescribers are required to call the toll free telephone number 1-877-309-9493 and respond to a series of questions that identify the prescriber, the patient and the reason for prescribing this drug. Prescribers should be prepared to provide patient information on the following topics and fax clinical documentation upon request:
- weight and body mass index (BMI)
- HIV/AIDS status, use of anti-viral therapy with good viral suppression, consultation with an HIV/AIDS specialist
- current nutritional regimen and if the patient has experienced unintentional weight loss (at least 5% from baseline) or has had significant weight loss recently (BMI<20mg/m2) in the absence of an opportunistic infection
- recent blood work (amylase, creatinine, fasting triglyceride level)
- active malignancy (other than Kaposi’s sarcoma), undergoing systemic chemotherapy or being treated with interferon, anabolic steroids or investigational drugs
- evidence of GI bleeding, intestinal obstruction, malabsorption syndrome, or severe liver dysfunction
- evidence of angina pectoris, coronary artery disease, congestive heart failure, renal failure, or serious chronic anemia
- history of glucose intolerance or uncontrolled hypertension
- trial and failure of other treatment modalities
- Prescriptions are limited to a maximum of a 28-day supply. Continuation beyond 28 days of therapy will require a new prescription and a new prior authorization.
- No refills for Serostim® are allowed. To continue treatment, the patient must be re-examined and a positive therapeutic response documented. If a determination to continue Serostim® therapy is made, the prescriber must write a new prescription and obtain a new prior authorization.
- If a patient has received a prior authorization for Serostim® recently, the prescriber will be informed of that issuance date. A new prior authorization for Serostim® should not be issued unless 75% of the previously authorized product has been used as determined by the previous issuance date.
- The clinical call center will inform prescribers if a patient has received three prior authorizations. The manufacturer's product information/package insert states "no significant additional efficacy was observed beyond 12 weeks". If a prescriber determines that continuation of Serostim® beyond 12 weeks/three prior authorizations is medically necessary, validating documentation must be available for review by the Department when requested.