Effective June 1, 2016

UNIVERSITY OF MICHIGAN – SEROSTIM (somatropin)

Some of the information needed to make a determination for coverage is not specifically requested on

the Michigan Prior Authorization Request Form for Prescription Drugs. To avoid delays in reviewing your

request, please make sure to include all of the following information.

Initial Requests:

1. Is the patient’s diagnosis AIDS wasting syndrome or cachexia? Y N

2. Is at least one of the following a true statement: (circle the true statement(s))

patient unintentionally lost at least 10% of body weight

patient’s weight is ≤ 90% than his/her respective lower ideal body weight limit

BMI ≤ 18.5 ?

Y N

3. Has the patient been evaluated for other underlying treatable conditions which can cause weight loss? (i.e., inadequate nutritional intake, malabsorption, opportunistic infections, hypogonadism, or depression)

Y N

4. Has the anti-retroviral therapy been optimized to decrease the viral load? Y N

Renewal Requests:

1. Is treatment providing clinical benefit such as stabilization of patient’s weight or promoting weight gain? Y N