somatropin — Medica

Initial criteria

• Endocrinologist certifies not prescribed for anti-aging, athletic enhancement, or bodybuilding
• Diagnosis of growth hormone deficiency that is either childhood onset OR adult onset resulting from pituitary or hypothalamic disease, pituitary surgery, cranial radiation therapy, tumor treatment, traumatic brain injury, or subarachnoid hemorrhage
• Patient meets ONE of the following: (i) known perinatal insults or congenital/genetic defects; OR (ii) has or had ≥3 pituitary hormone deficiencies before replacement, low age/gender-adjusted IGF-1, and other causes of low IGF-1 excluded; OR (iii) adult with negative response to at least one standard growth hormone stimulation test such as insulin tolerance, glucagon, arginine, clonidine, levodopa, or similar per listed thresholds

Approval duration

1 year