Requested agent (growth hormone products) — Blue Cross Blue Shield of Illinois
Other FDA labeled indication
Initial criteria
- Member resides in Ohio
- Plan is Fully Insured or HIM Shop (SG)
- Patient does NOT have any FDA labeled contraindications
- AND one of: another FDA labeled indication and route; indication supported in compendia; or prescriber provides ≥2 peer-reviewed journal articles supporting use (randomized, double-blind, placebo-controlled or equivalent; case studies not acceptable)
Approval duration
12 months