Norditropin — CareFirst (Caremark)
Noonan syndrome
Initial criteria
- Member has pretreatment height > 2 SD below mean and 1-year height velocity > 1 SD below mean OR pretreatment 1-year height velocity > 2 SD below mean; Epiphyses are open
Reauthorization criteria
- Member currently receiving growth hormone product indicated for Noonan syndrome; Epiphyses open; Growth rate > 2 cm/year unless clinical reason for lack of efficacy
Approval duration
12 months