Saizen — CareFirst (Caremark)
Russell-Silver syndrome
Initial criteria
- Authorization of 12 months when ALL:
- For members <2.5 years: pretreatment height >2 SD below mean and slow growth velocity
- For members ≥2.5 years: pretreatment height >2 SD below mean and 1-year height velocity >1 SD below mean OR 1-year velocity >2 SD below mean
- Epiphyses open
Reauthorization criteria
- Continuation authorization for 12 months if currently receiving GH therapy, epiphyses open, growth rate >2 cm/year unless clinically justified
Approval duration
12 months