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Genotropin — Cigna

Growth Disorders – Growth Hormone use per standard Prior Authorization Policy criteria

Preferred products

  • Omnitrope

Initial criteria

  • National Preferred Formulary: Approve if the patient meets the standard Growth Disorders – Growth Hormone Prior Authorization Policy criteria.
  • Basic Formulary: Approve if the patient meets the standard Growth Disorders – Growth Hormone Prior Authorization Policy criteria.
  • High Performance Formulary: Approve if the patient meets BOTH of the following (i and ii): i. Patient meets the standard Growth Disorders – Growth Hormone Prior Authorization Policy criteria; AND ii. Patient meets BOTH of the following (a and b): a. Patient has tried Omnitrope [documentation required]; AND b. Patient cannot continue to use Omnitrope due to a formulation difference in the inactive ingredient(s) which, according to the prescriber, would result in a significant allergy or serious adverse reaction [documentation required]. If the patient has met standard criteria but not met try/failure requirement, approve Omnitrope.