Nutropin AQ — CareFirst (Caremark)
Prader-Willi syndrome
Initial criteria
- Diagnosis confirmed by genetic testing showing deletion in chromosomal 15q11.2-q13 region OR maternal uniparental disomy in chromosome 15 OR imprinting defects, translocations, or inversions involving chromosome 15
Reauthorization criteria
- Member currently receiving growth hormone product indicated for Prader-Willi syndrome; Body composition and psychomotor function improved or stabilized on therapy
Approval duration
12 months