Target Short-Acting Growth Hormone Agent(s) — Blue Cross Blue Shield of Illinois

chronic renal insufficiency

Initial criteria

Patient is a child (open epiphysis)
Has one of the listed diagnoses
For each diagnosis, chart notes required
For chronic renal insufficiency: height >2 SD below mean AND serum creatinine >1.5 mg/dL or CrCl ≤75 mL/min/1.73 m2
For SGA: age ≥2 years, birth weight/length ≥2 SD below mean, failed catch-up growth at 24 months (height ≥2 SD below mean)
For GHD/short stature/growth failure: clinical diagnostic criteria as specified including stimulation test failure or pituitary defect or imaging evidence of open epiphyses as applicable
Patient does NOT have any FDA labeled contraindications
Prescriber is a specialist in the area of diagnosis or has consulted a specialist
Requested dose within FDA labeling or supported compendia
Request meets preferred or nonpreferred agent criteria: either preferred agent, or nonpreferred with documented reasons (current stable use, inadequate response, intolerance, contraindication, expected inefficacy, medical necessity, or better efficacy evidence as listed)

Previously approved for GH through prior authorization
Patient is a child (open epiphysis)
Request meets preferred/nonpreferred agent criteria same as initial
Prader-Willi: evidence of clinical benefit OR for other listed diagnoses (Turner, Noonan, SHOX, SGA, panhypopituitarism/multiple pituitary deficiency, chronic renal insufficiency, GHD/short stature/growth failure): imaging shows epiphyses not closed if female >12 or male >14, height or velocity improved since last approval
Patient monitored for adverse effects of GH therapy
No FDA labeled contraindications
Prescriber is a specialist or has consulted specialist
Requested dose within FDA labeling or supported compendia

12 months