Genotropin MiniQuick — Blue Cross Blue Shield of Texas

Preferred products

• Humatrope (somatropin)
• Norditropin FlexPro (somatropin)
• Nutropin AQ NuSpin (somatropin)
• Genotropin (somatropin)
• Genotropin MiniQuick (somatropin)
• Skytrofa (lonapegsomatropin-tcgd)

Initial criteria

• Patient is an adult (closed epiphysis)
• ONE of the following diagnoses is present:
• AIDS wasting/cachexia: requested agent is short-acting GH AND patient currently on and will continue antiretroviral therapy AND documented unintentional weight loss ≥10% over 12 months or ≥7.5% over 6 months OR BCM loss ≥5% within 6 months OR (if male) BCM <35% and BMI <27 kg/m^2 OR (if female) BCM <23% and BMI <27 kg/m^2 OR BMI <20 kg/m^2; all other causes of weight loss ruled out
• Short bowel syndrome (SBS): requested agent is short-acting GH AND patient receiving specialized nutritional support (chart notes required)
• Growth hormone deficiency (GHD)/growth failure: childhood-onset GHD AND failed ≥1 GH stimulation test as adult OR low IGF-1 plus pituitary lesion/trauma, or panhypopituitarism (≥3 deficiencies), or causal genetic mutation/hypothalamic-pituitary structural defect, OR failed ≥2 GH stimulation tests as adult (chart notes required)
• Prader-Willi syndrome: requested agent is short-acting GH (chart notes required)
• 3rd degree burns: requested agent is short-acting GH (chart notes required)
• For long-acting GH agents: agent must be FDA labeled for requested indication; patient's age within labeling or justified otherwise; no FDA labeled contraindications
• Prescriber is a relevant specialist (e.g., endocrinologist) or consults with one
• Requested dose within FDA labeling or supported in compendia
• If short-acting GH requested: must be preferred OR if nonpreferred, then documentation of one of the following: (1) request for Serostim for AIDS wasting/cachexia or Zorbtive for SBS OR (2) currently stable on requested agent OR (3) inadequate response to preferred agent OR (4) discontinued preferred due to lack of efficacy/adverse event OR (5) intolerance/FDA contraindication to preferred OR (6) preferred expected to be ineffective, hinder adherence, worsen comorbid condition, decrease function, or cause harm OR (7) preferred not in best interest after medical necessity review OR (8) tried another same-class drug with discontinuation due to lack of efficacy/effect/adverse event OR (9) evidence supports efficacy of requested agent over preferred agent
• If long-acting GH requested: agent FDA labeled for indication AND one of: (1) preferred short-acting agent not FDA labeled for indication OR (2) currently stable on requested agent OR (3) ≥12 months on preferred short-acting agent OR (4) inadequate response to preferred short-acting agent OR (5) discontinued due to lack of efficacy/adverse event OR (6) intolerance/contraindication to preferred short-acting agent OR (7) preferred short-acting expected to be ineffective, etc., OR (8) preferred not in best interest OR (9) tried another same-class drug discontinued OR similar logic for long-acting preferred vs nonpreferred selection

Reauthorization criteria

• Patient previously approved for GH therapy through plan prior authorization process

Approval duration

SBS: 3 months (BCBSMT/BCBSNM), 4 weeks (other plans); AIDS wasting/cachexia: 3 months (BCBSMT/BCBSNM), 12 weeks (other plans); all other indications: 12 months; 12 months for BCBSIL