- Quantity Limit: 1 vial per 1 day(s).
- Prior Authorization: Growth Hormone Deficiency:
Documented Diagnosis: Yes
Duration: 1 year(s)
Reauthorization Required: Yes
- Available only through Specialty Pharmacy;
- Growth Hormone Deficiency:
Duration: 1 year(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): 3 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 Growth Factor Binding Protein-3 (IGFBP-3) Level Required;Insulin-like Growth Factor 1 (IGF-1/Somatomedin-C) Level Required;Pretreatment growth hormone provocative test result(s) (laboratory report or medical record documentation)
Pediatric - GH Stimulation Test: <= 2
Pediatric - Pituitary Hormone Deficiency: >= 2
Pediatric - Reauthorization Requirement(s): 2 of Epiphyses is Open;Growth rate remains above 2.5 cm/year (does not apply with prior documented hypopituitarism);Sexual Maturity Rating (SMR, Tanner Stage) Required
Adult Growth Hormone Deficiency Requirement(s): 1 of Diagnosis of Adult-onset Growth Hormone Deficiency (GHD);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 - Duration of Reauthorization: N/A
Documented Diagnosis of Other Approved Indications: 1 of Chronic Renal Insufficiency;Growth Failure in Children Born Small for Gestational Age (SGA);Noonan Syndrome;Prader-Willi Syndrome in Children (PWS);Short Stature Homeobox-Containing Gene (SHOX);Turner's Syndrome (TS)
Documented Diagnosis: Yes
- Step Therapy: Growth Hormone Deficiency:
ST Multiple Brands
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