Omnitrope — Cigna

Non-Growth Hormone Deficient Short Stature (Idiopathic Short Stature) in a Child or Adolescent

Initial criteria

Approve for 6 months if ALL of the following (i, ii, iii, iv, v, vi, vii):
i. Patient age ≥ 5 years; AND
ii. Baseline height ≤ 1.2 percentile or standard deviation score ≤ -2.25 for age and gender; AND
iii. Growth (height) velocity ONE of the following:
a) Growth rate < 4 cm/year; OR
b) Growth velocity < 10th percentile for age and gender based on at least 6 months of growth data; AND
iv. Without growth hormone therapy, predicted adult height < 160 cm (63 inches) in males or < 150 cm (59 inches) in females; AND
v. Epiphyses are open; AND
vi. Patient does not have constitutional delay of growth and puberty; AND
vii. Medication prescribed by or in consultation with an endocrinologist.

Approve for 1 year if ONE of the following (i or ii):
i. Patient has received somatropin for ≥ 6 and < 10 months AND BOTH (a and b):
a) Age ≥ 5 years; AND
b) Annualized growth rate doubled compared to previous year; OR
ii. Patient has received somatropin for ≥ 10 months AND ONE of the following (a, b, or c):
a) Age ≥ 5 and < 12 years AND height increased by ≥ 2 cm/year in the most recent year; OR
b) Age ≥ 12 and < 18 years AND BOTH:
(1) Height increased by ≥ 2 cm/year in the most recent year; AND
(2) Epiphyses are open; OR
c) Age ≥ 18 years AND ALL:
(1) Height increased by ≥ 2 cm/year in the most recent year; AND
(2) Epiphyses are open; AND
(3) Mid-parental height has not been attained.

6 months initial, 1 year reauthorization