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Humatrope — Cigna

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

Preferred products

  • Genotropin
  • Omnitrope

Initial criteria

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