Somatropin — United Healthcare
Growth failure in children small for gestational age (SGA)
Initial criteria
- Diagnosis of growth failure associated with SGA
- Diagnosis confirmed by: (a) Growth charts for length/height and weight for age and gender AND (b) Birth weight or length ≥ 2 SD below mean for gestational age AND (c) Current length/height ≥ 2 SD below mean for age/gender at 2–3 years of age AND (d) Calculated growth velocity
- Prescribed by an endocrinologist
Reauthorization criteria
- Height increase ≥ 2 cm/year over previous year with documented measurements, calculated growth velocity, and growth chart
- Expected adult height not attained and goal documented
- Prescribed by an endocrinologist
Approval duration
12 months