Nutropin — Highmark

Growth Hormone Deficiency - Children

Preferred products

The member meets one (1) of the following criteria (i. or ii.):
i. The member is not a neonate and is using the product to treat documented growth failure due to inadequate secretion of endogenous growth hormone AND meets all of the following (A–F):
A) If the request is for Skytrofa, the member is age ≥ 1 year AND weighs ≥ 11.5 kg.
B) If the request is for Sogroya, the member is age ≥ 2.5 years.
C) If the request is for Ngenla, the member is age ≥ 3 years.
D) Clinical documentation (growth charts) indicates height at least 2 standard deviations below the age-appropriate mean OR growth velocity at least 2 standard deviations below the age-appropriate mean.
E) Subnormal response (< 10 ng/mL) to two standard GH stimulation tests (arginine, clonidine, glucagon, insulin, L-dopa, propranolol).
F) Bone age ≤ 14 years (female) OR ≤ 16 years (male).
ii. The member is a neonate using Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, or Zomacton AND has growth hormone level < 10 ng/mL.
If requesting a non-preferred growth hormone product, the member has experienced therapeutic failure or intolerance to all plan-preferred products.

Clinical documentation indicating growth velocity ≥ 2 cm/year OR growth velocity < 2 cm/year evaluated per adult criteria.
The member meets one (1) of: female with chronological age > 14 and bone age ≤ 14; male with chronological age > 16 and bone age ≤ 16; or female ≤ 14 years / male ≤ 16 years of age.