Humatrope — Medica

Growth hormone deficiency in a child or adolescent

Initial criteria

Approve for 1 year if ONE of the following (A or B) applies:
A) Initial therapy. Approve if ONE of the following (i, ii, iii, iv, or v):
i. Patient meets BOTH of the following (a and b):
a) Patient meets ONE of the following (1 or 2):
(1) Two growth hormone stimulation tests (with levodopa, insulin‑induced hypoglycemia, arginine, clonidine, or glucagon) each show peak GH < 10 ng/mL; OR
(2) ONE test (as above) shows peak GH < 10 ng/mL AND the patient has ≥ 1 risk factor for GH deficiency;
b) Risk factors for GH deficiency may include: downward deviation across ≥ 2 major height percentiles; growth rate less than age‑/gender‑expected; low IGF‑1 and/or IGFBP‑3; very low GH peak on provocative testing per prescriber; growth velocity < 10th percentile for age/gender; post‑craniopharyngioma status.

1 year