Target Short-Acting Agent(s) — Blue Cross Blue Shield of Texas

Noonan syndrome

Initial criteria

Patient is a child (open epiphysis)
Diagnosis meets one listed indication criterion (Turner, Noonan, Prader-Willi, SHOX, 3rd degree burns, panhypopituitarism, chronic renal insufficiency, SGA, or GHD/short stature/growth failure)
Member does not have closed epiphyses if female age >12 years or male age >14 years, or has Prader-Willi syndrome, or has 3rd degree burns
Patient does not have any FDA labeled contraindications to the requested agent
Prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist) or has consulted with one
Requested dose is within FDA labeled or compendia supported dosing for the indication
If nonpreferred agent requested, patient meets one of: stable on requested agent, inadequate response to preferred agent, discontinuation due to lack of efficacy/adverse event, intolerance/contraindication to preferred agent, preferred expected ineffective or unsafe, preferred not in best interest, or evidence supports efficacy of nonpreferred agent

Patient previously approved for GH therapy through plan’s PA process
Patient is a child (open epiphysis)
If nonpreferred agent requested, patient meets one of the same nonpreferred justification criteria as initial review
Prader-Willi syndrome with clinical benefit OR other listed diagnosis (Turner, Noonan, SHOX, SGA, panhypopituitarism, chronic renal insufficiency, or GHD/short stature/growth failure) with open epiphyses (female ≤12, male ≤14) and increased height or improved velocity since initiation/last approval
Patient monitored for adverse effects
No FDA labeled contraindications
Prescriber is a specialist or has consulted with one
Requested dose within FDA labeled or compendia supported dosing

12 months