Anthem Blue Cross (HMO, PPO, EPO)
Serostim 8.8 Mg Solr (somatropin)
Hormones : Drugs for Growth
  • Step Therapy Applies
  • Prior Authorization: Growth Hormone Deficiency:
    Documented Diagnosis: Yes
    Duration: 1 Day(s)
    Reauthorization Required: Yes

  • Growth Hormone Deficiency:
    Duration: 1 Day(s)
    Specialty Pharmacy Provider(s): 1 of Accredo Health Group, Inc.;Circle Care;The Pharmacy at Maine Medical Center
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified
    Pediatric Growth Hormone Deficiency (GHD) Requirement(s): 1 of Diagnosis of Pediatric Growth Hormone Deficiency;Documented Destructive Pituitary Lesion;Growth Velocity Required;Height Standard Deviation Score Required;History of Neonatal Hypoglycemia Required;Insulin-like Growth Factor 1 (IGF-1/Somatomedin-C) Level Required
    Pediatric - GH Stimulation Test: >= 2
    Pediatric - Pituitary Hormone Deficiency: >= 2
    Pediatric - Reauthorization Requirement(s): 1 of Epiphyses is Open;Increase in growth rate;Sexual Maturity Rating (SMR, Tanner Stage) Required
    Adult Growth Hormone Deficiency Requirement(s): 1 of Diagnosis of Childhood-onset Growth Hormone Deficiency (GHD);Documented Destructive Pituitary Lesion
    Adult - GHD Stimulation Test: >= 1
    Adult - Pituitary Hormone Deficiency: >= 3
    Adult - Duration of Initial Authorization: N/A
    Adult - Reauthorization Requirement(s): Other requirement(s)
    Adult - Duration of Reauthorization: Unspecified
    Documented Diagnosis of Other Approved Indications: 1 of AIDs/HIV Associated Wasting or Cachexia;Short Bowel Syndrome (SBS)
    Documented Diagnosis: Yes

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