Zomacton — Point32Health

Preferred products

• Omnitrope

Initial criteria

• Patient age < 18 years
• Documented diagnosis with short stature or growth failure due to one (1) of the listed conditions
• Prescribed by or in consultation with an endocrinologist or nephrologist

Reauthorization criteria

• Patient age < 18 years
• Documented diagnosis with short stature or growth failure due to one (1) of the listed conditions
• Prescribed by or in consultation with an endocrinologist or nephrologist
• Documentation patient’s epiphyses are open confirmed by radiograph of the wrist and hand
• Documentation of therapeutic response defined as growth velocity ≥ 2 cm compared with previous year
• If diagnosis is chronic renal failure, documentation patient has not received a kidney transplant

Approval duration

12 months