Norditropin — CareFirst (Caremark)

Adult growth hormone deficiency (childhood-onset or adult-onset)

Initial criteria

Authorization of 12 months when ANY of:
1) Two pretreatment pharmacologic GH tests with deficient responses (ITT ≤5 ng/mL, Macrilen <2.8 ng/mL, or glucagon test ≤3.0 ng/mL for BMI ≤30 or ≤1.0 ng/mL for BMI ≥25/30) AND pretreatment IGF-1 level 0–2 SD below mean;
2) One GH test as above AND IGF-1 >2 SD below mean;
3) Organic hypothalamic-pituitary disease with ≥3 pituitary hormone deficiencies AND IGF-1 >2 SD below mean;
4) Genetic/congenital structural hypothalamic-pituitary defects;
5) Childhood-onset GH deficiency with congenital CNS/hypothalamic/pituitary abnormality

Continuation authorization of 12 months when member is currently receiving GH therapy for adult GH deficiency

12 months