Saizen — CareFirst (Caremark)

Adult growth hormone deficiency

Initial criteria

Any of the following: (1) Two pretreatment pharmacologic provocative GH tests showing deficient response (ITT ≤ 5 ng/mL, Macrilen < 2.8 ng/mL, or Glucagon stimulation ≤ 3.0 ng/mL or ≤ 1.0 ng/mL depending on BMI) and pretreatment IGF-1 level 0–2 SD below mean; OR (2) One pretreatment pharmacologic GH test showing deficient response (same test options) and pretreatment IGF-1 > 2 SD below mean; OR (3) Organic hypothalamic-pituitary disease with ≥ 3 pituitary hormone deficiencies and pretreatment IGF-1 > 2 SD below mean; OR (4) Genetic or congenital structural hypothalamic-pituitary defects; OR (5) Childhood-onset GH deficiency with congenital abnormality of CNS, hypothalamus, or pituitary

Member currently receiving growth hormone product indicated for adult GH deficiency

12 months