somatropin — Medica
Growth hormone deficiency in a child or adolescent
Initial criteria
- Patient has ONE of the following: (i) growth hormone deficiency due to hypothalamic or pituitary disease or injury or congenital defect; OR (ii) brain radiation or tumor resection; OR (iii) congenital hypopituitarism; OR (iv) multiple pituitary hormone deficiencies; OR (v) hypophysectomy
- Meet diagnostic testing criteria under chosen category (stimulation test with growth hormone peak <10 ng/mL OR presence of other pituitary hormone deficiencies OR imaging findings as specified)
- Medication prescribed by or in consultation with an endocrinologist
Reauthorization criteria
- Patient has been receiving somatropin for ≥10 months
- If age <12 years: height increase ≥2 cm/year in most recent year; OR
- If age ≥12 years and <18 years: height increase ≥2 cm/year AND epiphyses open; OR
- If age ≥18 years: height increase ≥2 cm/year AND epiphyses open AND mid-parental height not attained
Approval duration
6 months initial, 1 year continuation