- 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
- Prior Authorization: Neutropenia:
PA Applies
- ST_APPLIES
- Available only through Specialty Pharmacy;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE; Dosing Limit: 5 mg/ kg every 4 weeks;
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