- Prior Authorization: Growth Hormone Deficiency:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- Step Therapy: Growth Hormone Deficiency:
ST Multiple Brands
- Growth Hormone Deficiency:
Duration: 6 Month(s)
Specialist Required: Yes
Specialist Type(s): 1 of Endocrinologist;Pediatric Endocrinologist
Reauthorization Required: Yes
Duration of Reauthorization: >= 6 month(s)
Pediatric Growth Hormone Deficiency (GHD) Requirement(s): 3 of Diagnosis of Pediatric Growth Hormone Deficiency;Epiphyses is Open;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
Pediatric - GH Stimulation Test: = 2
Pediatric - Pituitary Hormone Deficiency: >= 1
Pediatric - Reauthorization Requirement(s): 2 of Increase in growth rate;Positive response to therapy
Adult Growth Hormone Deficiency Requirement(s): 3 of Cannot be used for athletic performance enhancement;Diagnosis of Adult-onset Growth Hormone Deficiency (GHD);Diagnosis of Childhood-onset Growth Hormone Deficiency (GHD);Insulin-like Growth Factor 1 (IGF-1/Somatomedin-C) Level Required
Adult - GHD Stimulation Test: >= 1
Adult - Pituitary Hormone Deficiency: >= 3
Adult - Duration of Initial Authorization: >= 6 month(s)
Adult - Reauthorization Requirement(s): 3 of Cannot be used for athletic performance enhancement;Insulin-like Growth Factor 1 (IGF-1) Required;Positive response to therapy
Adult - Duration of Reauthorization: >= 6 month(s)
Documented Diagnosis of Other Approved Indications: 1 of AIDs/HIV Associated Wasting or Cachexia;Chronic Renal Insufficiency;Growth Failure in Children Born Small for Gestational Age (SGA);Idiopathic Short Stature (ISS);Noonan Syndrome;Prader-Willi Syndrome in Children (PWS);Short Bowel Syndrome (SBS);Short Stature Homeobox-Containing Gene (SHOX);Turner's Syndrome (TS)
Documented Diagnosis: Yes
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