Saizen — CareFirst (Caremark)
Short stature homeobox-containing gene (SHOX) deficiency
Initial criteria
- Diagnosis confirmed by molecular or genetic analyses; Member has 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 SHOX deficiency; Epiphyses open; Growth rate > 2 cm/year unless clinical reason for lack of efficacy
Approval duration
12 months