Nutropin AQ — CareFirst (Caremark)
Small for gestational age (SGA)
Initial criteria
- Member meets at least one: birth weight < 2500 g at gestational age > 37 weeks OR birth weight or length < 3rd percentile for gestational age OR birth weight or length ≥ 2 SD below mean; Pretreatment age ≥ 2 years; Failed to manifest catch-up growth by age 2 (pretreatment height > 2 SD below mean); Epiphyses are open
Reauthorization criteria
- Member currently receiving growth hormone product indicated for SGA; Epiphyses are open; Member's growth rate > 2 cm/year unless documented reason for lack of efficacy
Approval duration
12 months