Sogroya — Blue Cross Blue Shield of Oklahoma
pediatric growth hormone deficiency (GHD) or growth failure due to inadequate secretion of endogenous growth hormone
Preferred products
- Humatrope
- Norditropin FlexPro
- Nutropin AQ NuSpin
- Omnitrope
- Saizen
- Saizenprep
- Zomacton
Initial criteria
- Patient has diagnosis of GHD or growth failure due to inadequate secretion of endogenous GH AND
- Either extreme short stature (height ≤ -3 SD), normal nutrition, reduced IGF-1 and IGFBP-3 (≤ -2 SD), and delayed bone age OR BOTH of: (A) pretreatment height >2 SD below mean OR height velocity (HV) >2 SD below mean OR HV <10th percentile AND (B) failed at least 2 GH stimulation tests (peak GH<10 mcg/L) OR failed 1 GH stimulation test with CNS pathology OR irradiation history OR other pituitary hormone defects (MPHD) OR genetic defect
Approval duration
not specified