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The Policy VaultThe Policy Vault

Saizen — Blue Cross Blue Shield of Illinois

growth hormone deficiency (GHD) or growth failure due to inadequate secretion of endogenous growth hormone

Preferred products

  • Humatrope
  • Norditropin FlexPro
  • Nutropin AQ NuSpin
  • Genotropin
  • Genotropin MiniQuick
  • Omnitrope

Initial criteria

  • Patient is an adult (closed epiphysis)
  • Diagnosis is one of: AIDS wasting/cachexia, SBS, GHD/growth failure, Prader-Willi syndrome, or 3rd degree burns
  • For AIDS wasting/cachexia: requested agent is short-acting GH AND patient is currently and will continue antiretroviral therapy AND documentation of qualifying weight or body composition loss AND other causes ruled out
  • For SBS: requested agent is short-acting GH AND patient is receiving specialized nutritional support
  • For GHD: childhood-onset GHD with failed GH stimulation test as an adult OR low IGF-1 with pituitary structural lesion/trauma OR ≥3 pituitary hormone deficiencies OR causal genetic mutation or hypothalamic-pituitary structural defect OR failed ≥2 GH stimulation tests as adult
  • For Prader-Willi: requested agent is short-acting GH AND diagnosis documented
  • For 3rd degree burns: requested agent is short-acting GH AND diagnosis documented
  • If long-acting GH requested: indication must be within FDA labeling OR medically supported for the age, and patient has no contraindications
  • Prescriber is a specialist in the relevant area or has consulted with one
  • Requested dose is within FDA labeled or compendia-supported range
  • Step Therapy: If short-acting GH nonpreferred, approval if Serostim for AIDS wasting or Zorbtive for SBS OR patient stable on current nonpreferred OR inadequate response, intolerance, contraindication, diminished effect, adverse event, or medical necessity reason preventing use of preferred; if long-acting GH, must meet similar step therapy logic after trial/intolerance/failure of preferred short-acting or long-acting GH agents as described

Reauthorization criteria

  • Patient previously approved for therapy with GH through plan prior authorization process; otherwise must meet initial criteria

Approval duration

12 months (default); SBS 3 months (BCBSMT/NM)/4 weeks (other); AIDS wasting/cachexia 3 months (BCBSMT/NM)/12 weeks (other)