- Prior Authorization: Duchenne Muscular Dystrophy (DMD):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: <= 13
Duration: 6 Month(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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