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Effective Date: 
4/2018

Documents

Instructions

Updated: 10/2017

 

PURPOSE

Growth hormones are covered for the treatment of people with specific diagnoses involving growth hormone deficiency. If an initial or extension request cannot be approved based on the above criteria, the approval request may be sent for medical review and reconsideration to the Children with Special Health Care Needs (CSHCN) Services Program. 

 

 

PROCEDURE

When to Prepare

This form is only used for people enrolled in the CSHCN Services Program.

A program-approved prescribing physician must complete and sign this form annually certifying that the individual continues to require these medications.

Requests must be signed and submitted by the prescribing physician.  Please complete all requested information or document why information is not available.

The addendum must accompany the Texas Department of Insurance Standard Prior Authorization Form (PDF) (link is external).

Transmittal

Staff sends the form to the CSHCN-enrolled pharmacy, who then forwards the completed form by fax or mail:

Fax:    512-776-7238

Mail:  Texas Health and Human Services

Children with Special Health Care Needs Services Program (MC-1938)

P.O. Box 149347

Austin, TX 78714-9347

 

Form Retention

There is no retention requirement.

 

DETAILED INSTRUCTIONS

  1. If a person is enrolled in a CSHCN service program an approved prescribing physician will complete this form.
  2.  The prescribing physician must supply medical necessity documentation for people with specific diagnoses involving growth hormone deficiency.
  3. The prescribing physician must sign and submit the form completing all applicable fields.
  4. If information in not available, the prescribing physician must document why the information is not available. 
  5. Direct all questions about this form to the CSHCN Services Program at 800-252-8023.