Saizenprep (somatropin) — Blue Cross Blue Shield of Alabama
Children with growth hormone deficiency (GHD), growth failure due to inadequate GH secretion, Turner syndrome, Noonan syndrome, Prader-Willi syndrome, SHOX gene deficiency, short bowel syndrome, panhypopituitarism, chronic renal insufficiency, small for gestational age, or idiopathic short stature
Preferred products
- Genotropin (somatropin)
- Genotropin MiniQuick (somatropin)
- Omnitrope (somatropin)
Initial criteria
- Patient is a child (as defined by prescriber)
- Diagnosis criteria match any specified pediatric GH indication (per condition details and test thresholds in policy)
- For SBS: patient receiving specialized nutritional support AND age within FDA labeling or supported for use
- For SGA: ≥2 years old, documented birth data ≤ -2 SD, failed catch-up growth at 24 months (height ≤ -2 SD)
- For ISS: height ≤ -2.25 SD, open epiphyses, documented predicted adult height below normal range (males <63 in, females <59 in, or >2 SD below midparental target height), evaluated for and no CDGP
- For GHD: abnormal GH stimulation results meeting the detailed criteria
- Patient has no FDA-labeled contraindications
- Requested dose within FDA labeling or supported in compendia (AHFS or DrugDex 1 or 2a)
Approval duration
12 months