Omnitrope — Highmark

Initial criteria

• Diagnosis of Prader-Willi Syndrome (ICD-10: Q87.11)
• If female, bone age ≤ 14 years OR if male, bone age ≤ 16 years
• If request is for a non-preferred growth hormone product, member has experienced therapeutic failure or intolerance to all plan-preferred products

Reauthorization criteria

• Clinical documentation indicating a growth velocity of at least 2 cm/year
• Female with chronological age > 14 years and bone age ≤ 14 years OR male with chronological age > 16 years and bone age ≤ 16 years OR female with chronological age ≤ 14 years OR male with chronological age ≤ 16 years

Approval duration

12 months