- Step Therapy Applies
- Quantity Limit: 1 injection per 1 day(s).
- 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;
- PA Applies
- 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
- Prior Authorization: Growth Hormone Deficiency:
Documented Diagnosis: Yes
Duration: 1 Day(s)
Reauthorization Required: Yes
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