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Omnitrope — Highmark

Growth Hormone Deficiency - Adults

Preferred products

  • Genotropin
  • Humatrope
  • Omnitrope
  • Norditropin

Initial criteria

  • Product is used for replacement of endogenous GH in adults with GH deficiency AND one (1) of the following:
  • Documentation of multiple pituitary GH deficiencies OR documentation of CNS irradiation OR reconfirmed adult GH deficiency defined as all of:
  • Epiphyseal fusion has occurred.
  • Member has not used GH for at least 1 month.
  • Response to stimulation tests meets thresholds: one of (arginine ≤ 4.1 ng/mL OR macimorelin < 2.8 ng/mL) AND one of (insulin ≤ 5 ng/mL OR glucagon ≤ 3 ng/mL for BMI ≤ 25 or ≤ 1 ng/mL for BMI > 25).
  • If requesting a non-preferred product, member has experienced therapeutic failure or intolerance to all plan-preferred products.
  • If Sogroya requested, dose ≤ 8 mg once weekly.

Reauthorization criteria

  • Prescriber attests to positive clinical response to therapy.
  • If Sogroya requested, dose ≤ 8 mg once weekly.