Omnitrope — Highmark
Idiopathic Short Stature (ISS) – Children
Preferred products
- Genotropin
- Humatrope
- Omnitrope
- Norditropin
Initial criteria
- Diagnosis of ISS (ICD-10: R62.52).
- Height <2.25 SD below the age-appropriate mean.
- Growth velocity <10th percentile over 12 months.
- If female, bone age ≤14 years OR if male, bone age ≤16 years.
- If requesting a non-preferred product, member has therapeutic failure or intolerance to all preferred products.
Reauthorization criteria
- Clinical documentation (growth charts) indicating continued positive growth response as defined in initial criteria.