Zomacton — Highmark
Small for Gestational Age (SGA)
Initial criteria
- Diagnosis of SGA (ICD-10: P05.1X)
- Failed to have catch-up growth by 2 years of age
- Birth weight at least 2 standard deviations below the gestational age-appropriate mean OR birth crown-heel length at least 2 standard deviations below the gestational age-appropriate mean
- If request is for a non-preferred growth hormone product, member has experienced therapeutic failure or intolerance to all 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