Nutropin AQ — CareFirst (Caremark)
Growth failure due to chronic kidney disease, cerebral palsy, congenital adrenal hyperplasia, cystic fibrosis, or Russell-Silver syndrome
Initial criteria
- For members < 2.5 years at initiation, pretreatment height > 2 SD below mean and growth velocity slow; For members ≥ 2.5 years, either 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 open
Reauthorization criteria
- Member currently receiving growth hormone product indicated for the same diagnosis; Epiphyses open; Growth rate > 2 cm/year unless documented reason for lack of efficacy
Approval duration
12 months