Saizen — Blue Cross Blue Shield of New Mexico

Preferred products

• Humatrope (somatropin)
• Norditropin FlexPro (somatropin)
• Nutropin AQ NuSpin (somatropin)
• Genotropin
• Genotropin MiniQuick
• Omnitrope

Initial criteria

• Patient is adult (closed epiphysis)
• For AIDS wasting/cachexia ALL of: requested agent is short-acting GH AND patient is on antiretroviral therapy and will continue it AND meets one of weight loss/body cell mass/BMI criteria AND all other causes of weight loss ruled out
• For short bowel syndrome BOTH: requested agent is short-acting GH AND patient is receiving specialized nutritional support
• For growth hormone deficiency/growth failure: diagnosis of childhood-onset GHD and failed ≥1 GH stimulation test as adult OR low IGF-1 and pituitary lesion/trauma OR panhypopituitarism/multiple pituitary hormone deficiencies OR causal genetic mutation or hypothalamic-pituitary structural defect OR failed ≥2 GH stimulation tests as adult
• For Prader-Willi syndrome BOTH: requested agent is short-acting GH AND diagnosis confirmed
• For 3rd degree burns BOTH: requested agent is short-acting GH AND diagnosis confirmed
• Request for long-acting GH agent requires FDA-labeled indication and age within labeling or medically supported use, no FDA-labeled contraindications, prescriber is a specialist or consulted one, dose within labeling/compendia
• If short-acting GH requested: must be preferred agent OR if nonpreferred, patient meets one of: Serostim for AIDS wasting/zorbtive for SBS OR stable on current therapy OR inadequate response to preferred OR preferred discontinued for inefficacy/adverse event OR intolerance/contraindication to preferred OR preferred expected ineffective/barrier/adverse reaction OR preferred not in best interest/medical necessity OR prior drug in same class failed OR support for efficacy over preferred
• If long-acting GH requested: must be FDA labeled AND meets one of: preferred short-acting GH not labeled OR stable on current long-acting agent OR ≥12 months therapy with preferred short-acting GH OR inadequate response/adverse event/contraindication similar as short-acting criteria; then must meet one of: preferred long-acting not labeled OR stable on requested OR ≥12 months with preferred long-acting OR inadequate response/adverse/contraindication/ineffectiveness/medical necessity as above

Reauthorization criteria

• Patient has previously been approved for GH through plan’s prior authorization process (patients not previously approved require initial evaluation)

Approval duration

SBS 3 months (BCBSMT/BCBSNM) or 4 weeks (other plans); AIDS wasting/cachexia 3 months (BCBSMT/BCBSNM) or 12 weeks (other plans); all other indications 12 months