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Norditropin — 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 ingredients which would result in significant allergy or serious adverse reaction [documentation required]. If criteria not met, 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 in inactive ingredients leading to allergy or serious adverse reaction. 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 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 not met, approve Omnitrope.