Somatropin — United Healthcare

growth hormone deficiency (pediatric GHD)

Initial criteria

One of the following: request does not exceed a maximum supply limit of 0.3 mg/kg/week OR both of the following: (i) one of the following: poor catch-up growth on standard dosing OR IGF-1 < 2 SD from the mean while on standard dosing; (ii) Tanner Stage 2 or greater; (iii) request does not exceed a maximum supply limit of 0.7 mg/kg/week
Prescribed by an endocrinologist

Submission of medical records documenting a height increase at least 2 cm/year over the previous year of treatment as confirmed by all of the following: previous length/height and date obtained, current length/height and date obtained, calculated growth velocity, growth chart for height for age and gender
Submission of medical records documenting both of the following: expected adult height not attained, expected adult height goal
One of the following: request does not exceed a maximum supply limit of 0.3 mg/kg/week OR all of the following: (i) one of the following: poor catch up growth while on standard dosing OR IGF < 2 SD from the mean while on standard dosing; (ii) Tanner Stage 2 or greater; (iii) request does not exceed a maximum supply limit of 0.7 mg/kg/week
Prescribed by an endocrinologist

12 months