Growth Hormone Covered Indications (prior to epiphyseal closure)*:
- Growth hormone deficiency (GHD) of 1 of the following types:
- Classic GHD as determined by childhood GH stimulation tests; or
- Panhypopituitarism; or
- Hypoglycemia with evidence for GHD; or
- Neurosecretory dysfunction; or
- Other evidence for GHD submitted for panel review and decision; or
- Short stature associated with Prader-Willi Syndrome; or
- Short stature associated with Noonan Syndrome; or
- Short stature associated with chronic renal insufficiency (pre-transplantation); or
- Growth failure in children born small for gestational age (SGA) who fail to manifest catch-up growth by 2 years of age; or
- Idiopathic short stature (ISS) in children with height ≥2.25 SD below the mean for age and gender and who are unlikely to catch up in height; or
- Turner syndrome or 45X, 46XY mosaicism; or
- Short-stature homeobox-containing gene (SHOX) deficiency with genetic evidence for SHOX deficiency.
*Please refer to the complete prior authorization criteria for each indication, listed below.
Growth Hormone Tier-2 Approval Criteria:
- Documented allergic reaction to non-active components of all available Tier-1 products; or
- A clinical exception applies to members with a diagnosis of acquired immunodeficiency syndrome (AIDS) wasting syndrome, in which case Serostim® can be used regardless of its current Tier status; or
- A clinical exception applies to members with a diagnosis of short bowel syndrome (SBS), in which case Zorbtive® can be used regardless of its current Tier status.
Discontinuation of Therapy or Transition to Adult Therapy Criteria:
- Failure to show improvement in height percentile on growth chart after 1 year of treatment; or
- Growth velocity <2.5cm/year unless associated with another growth-limiting and treatable medical condition (i.e., hypothyroidism); or
- Epiphyseal closure; or
- Covered height has been reached:
- 152.4cm (60 inches) for girls; or
- 165.1cm (65 inches) for boys; or
- The covered height does not apply for members with a diagnosis of growth hormone deficiency (GHD) or panhypopituitarism; or
- Inadequate compliance; or
- Significant adverse effects.
Growth Hormone Dosing (doses must be individualized and titrated):
- Children: 22 to 100mcg/kg/day according to current pediatric guidelines; or
- Adults:
- Initial Dosing: 0.1 to 0.5mg per day – Doses should be evaluated and titrated at 1 to 2 month intervals targeting an insulin-like growth factor 1 (IGF-1) level within the age-adjusted reference range provided by the laboratory utilized [IGF-1 standard deviation score (SDS) between -2 and +2]. In general, younger patients may require higher doses than older patients. The following initial doses are suggested by the current American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) guidelines, but these doses should be titrated based on IGF-1 levels:
- Age <30 years: 0.4 to 0.5mg per day (may be higher for patients transitioning from pediatric treatment); or
- Age 30-60 years: 0.2 to 0.3mg per day; or
- Age >60 years: 0.1 to 0.2mg per day; and
- Transition Dosing: In patients transitioning from pediatric to adult dosing, resuming GH doses at 50% of the dose last used in childhood is suggested, as they tend to be more tolerant of higher doses.
Growth Hormone Deficiency (GHD) Approval Criteria:
- Initial Approval:
- Member must be 2 years of age or older (unless hypoglycemia is present); and
- Growth hormone therapy must be prescribed by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); and
- Member must meet at least 1 of the following:
- Member’s growth velocity (GV) must be <10% on a GV curve for gender and age; or
- Member must have evidence of delayed bone age (undefined delay); and
- Member must have open epiphyses; and
- Member’s height must be ≥2.25 standard deviations (SD) below the mean for age and gender; and
- Member’s growth chart and parental heights must be provided; and
- If the form is completed, a growth chart is not required; and
- Parental heights are not always available; and
- There must be no contributing medical conditions (e.g., cystic fibrosis, malnutrition, psychosocial deprivation); and
- Member must have suboptimal response of ≤10ng/mL on 2 of the following provocative growth hormone stimulation tests, using the highest level per date of testing. (Stimulation tests are always required for approval unless hypoglycemia is observed, in which case a random low glucose level and low growth hormone level would be acceptable):
- Propranolol with exercise; or
- Levodopa; or
- Insulin hypoglycemia test; or
- Arginine HCl infusion; or
- Clonidine; or
- Glucagon (not approved for use in children); or
- If hypoglycemia is present and member is growth hormone deficient: request may be approved for 6 months (other criteria above is not applicable). If the member has hypoglycemia, a low glucose level must be submitted along with additional evidence of GHD such as:
- Low insulin-like growth factor 1 (IGF-1), random growth hormone level, or suboptimal growth hormone stimulation tests; or
- MRI evidence of congenital anomaly which includes pituitary damage or absence; or
- Other pituitary hormones also being replaced (e.g., thyroid, cortisol, etc.).
- Approval Length: 6 months if criteria met, compliant, and not needing to transition to adult dosing.
- Dosing:
- Pediatric Dosing: FDA approved dosing varies by product. See the “Growth Hormone Dosing” section above for current guideline-based dosing considerations; OR
- Adult Dosing: Members with this diagnosis may transition to adult dosing (see “Growth Hormone Dosing” section above for recommendations for adult and transition dosing) after 1 or both of the following:
- Epiphyseal closure; or
- GV <2.5cm/year; and
- If either of the above have occurred and the member has not yet transitioned to adult dosing, may be approved short term (3 months) to allow time for transition to adult dosing.
- Continuation Approval:
- Medications and dosing should be appropriate; and
- Member should have had a recent office visit with new information regarding heights provided; and
- Member should be compliant; and
- GV should not be <2.5cm/year if not on adult dosing; and
- For members on adult dosing, recent IGF-1 level and standard deviation score (SDS) should be submitted and SDS should be between -2 and +2.
Panhypopituitarism Approval Criteria:
- Initial Approval:
- Member must be 2 years of age or older (unless hypoglycemia is present); and
- Growth hormone therapy must be prescribed by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); and
- Member must meet at least 1 of the following:
- Member’s growth velocity (GV) must be <10% on a GV curve for gender and age; or
- Member must have evidence of delayed bone age (undefined delay); and
- Member must have open epiphyses; and
- Member’s height must be ≥2.25 standard deviations (SD) below the mean for age and gender; and
- For members with secondary panhypopituitarism due to tumor, trauma, or surgery 12 months post trauma or surgery, approval may be granted if no evidence of tumor recurrence and growth has not restarted. The member must still meet all the other criteria; however, authorization would not require height ≥2.25 SD below the mean in these circumstances; and
- Member’s growth chart and parental heights must be provided; and
- If the form is completed, a growth chart is not required; and
- Parental heights are not always available; and
- Member must have a history of pituitary or hypothalamic injury due to tumor, trauma, surgery, documented whole brain radiation, irradiation, hemorrhage or infarction, or a congenital anomaly; and
- Deficiency in ≥3 pituitary hormones and insulin-like growth factor 1 (IGF-1) ≥2.5 SD below the mean for member’s age; or
- No deficiency, or deficiency in <3 pituitary hormones, and IGF-1 <50th percentile and subnormal response of 10ng/mL or less on at least 2 provocative growth hormone stimulation tests, using the highest level per date of testing. (Stimulation tests are always required for approval unless hypoglycemia is observed, in which case a random low glucose level and low growth hormone level would be acceptable); or
- If member has MRI evidence of pituitary stalk agenesis, empty sella, or ectopic posterior pituitary “bright spot”, member is exempt from height requirement (criteria letter e listed above); and
- If they lack the hormones testosterone, luteinizing hormone (LH), or follicle-stimulating hormone (FSH) then an MRI is not required; or
- If hypoglycemia is present and member is growth hormone deficient: request may be approved for 6 months (other criteria above is not applicable). If the member has hypoglycemia, a low glucose level must be submitted along with additional evidence of GHD such as:
- Low IGF-1, random growth hormone level, or suboptimal growth hormone stimulation tests; or
- MRI evidence of congenital anomaly which includes pituitary damage or absence; or
- Other pituitary hormones also being replaced (e.g., thyroid, cortisol); and
- Approval Length: 6 months if criteria met, compliant, and not needing to transition to adult dosing.
- Dosing:
- Pediatric Dosing: FDA approved dosing varies by product. See the “Growth Hormone Dosing” section above for current guideline-based dosing considerations; OR
- Adult Dosing: Members with this diagnosis may transition to adult dosing (see “Growth Hormone Dosing” section above for recommendations for adult and transition dosing) after 1 or both of the following:
- Epiphyseal closure; or
- GV <2.5cm/year; and
- If either of the above have occurred and the member has not yet transitioned to adult dosing, may be approved short term (3 months) to allow time for transition to adult dosing.
- Continuation Approval:
- Medications and dosing should be appropriate; and
- Member should have had a recent office visit with new information regarding heights provided; and
- Member should be compliant; and
- GV should not be <2.5cm/year if not on adult dosing; and
- For members on adult dosing, recent IGF-1 level and standard deviation score (SDS) should be submitted and SDS should be between -2 and +2.
Neurosecretory Dysfunction Approval Criteria:
- Initial Approval:
- Member must be 2 years of age or older; and
- Growth hormone therapy must be prescribed by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); and
- Member’s growth velocity (GV) must be <10% on a GV curve for gender and age; and
- Member’s height must be ≥2.25 standard deviations (SD) below the mean for age and gender; and
- Member must have evidence of delayed bone age and open epiphyses; and
- Member’s growth chart and parental heights must be provided; and
- If the form is completed, a growth chart is not required; and
- Parental heights are not always available; and
- Member’s serum insulin-like growth factor 1 (IGF-1) must be below the mean for member’s age; and
- Note: Children with profoundly low GV, who are at risk for growth hormone deficiency due to CNS radiation or other organic causes, termed neurosecretory dysfunction, may demonstrate “normal” responses to provocative tests, often for several years, but often benefit from growth hormone therapy.
- Growth hormone stimulation testing is required; however, growth hormone levels may be normal; and
- Approval Length: 6 months if criteria met, compliant, and not needing to transition to adult dosing.
- Dosing:
- Pediatric Dosing: FDA approved dosing varies by product. See the “Growth Hormone Dosing” section above for current guideline-based dosing considerations; OR
- Adult Dosing: Members with this diagnosis may transition to adult dosing (see “Growth Hormone Dosing” section above for recommendations for adult and transition dosing) after 1 of the following:
- Epiphyseal closure; or
- Covered height [Boys: 165.1cm (65 inches); Girls: 152.4cm (60 inches)]; or
- GV <2.5cm/year; and
- If any of the above have occurred and the member has not yet transitioned to adult dosing, may be approved short term (3 months) to allow time for transition to adult dosing.
- Continuation Approval:
- Medications and dosing should be appropriate; and
- Member should have had a recent office visit with new information regarding heights provided; and
- Member should be compliant; and
- GV should not be <2.5cm/year if not on adult dosing; and
- For members on adult dosing, recent IGF-1 level and standard deviation score (SDS) should be submitted and SDS should be between -2 and +2.
Idiopathic Short Stature Approval Criteria:
- Initial Approval:
- Member must be 8 years of age or older; and
- Growth hormone therapy must be prescribed by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); and
- Member’s growth velocity (GV) must be <10% on a GV curve for gender and age; and
- Member’s height must be ≥2.25 standard deviations (SD) below the mean for age and gender; and
- Member must have evidence of delayed bone age (undefined delay) and open epiphyses; and
- Member’s growth chart and parental heights must be provided
- If the form is completed, a growth chart is not required; and
- Parental heights are not always available; and
- Approval Length: 6 months if criteria met and compliant. No adult dosing will be approved for this indication. Once epiphyses are closed, covered height has been met, or GV is <2.5cm/year, therapy should be discontinued.
- Dosing:
- Pediatric Dosing: FDA approved dosing varies by product. See the “Growth Hormone Dosing” section above for current guideline-based dosing considerations. Treatment may continue until 1 of the following:
- Epiphyseal closure; or
- Covered height [Boys: 165.1cm (65 inches); Girls: 152.4cm (60 inches)]; or
- GV <2.5cm/year; and
- Adult Dosing: No proven benefit to continuing growth hormone treatment in adulthood.
- Continuation Approval:
- Medications and dosing should be appropriate; and
- Member should have had a recent office visit with new information regarding heights provided; and
- Member should be compliant; and
- Epiphyses are open; and
- GV should not be <2.5cm/year.
Short Stature Associated with Chronic Renal Insufficiency (Pre-Transplantation) Approval Criteria:
- Initial Approval:
- Member must be 2 years of age or older; and
- Member’s estimated creatinine clearance (CrCl) must be <50mL/min; and
- Member must not be post-kidney transplant; and
- Growth hormone therapy must be prescribed by an endocrinologist or pediatric nephrologist (or an advanced care practitioner with a supervising physician who is an endocrinologist or pediatric nephrologist); and
- Member’s growth chart and parental heights must be provided; and
- If the form is completed, a growth chart is not required; and
- Parental heights are not always available; and
- Members meeting the above criteria are exempt from height requirements.
- Approval Length: 6 months if criteria met and compliant. No adult dosing will be approved for this indication. Once epiphyses are closed, covered height has been met, growth velocity (GV) is <2.5cm/year, or member has received renal transplant, therapy should be discontinued.
- Dosing:
- Pediatric Dosing: Standard dosing applies for members receiving pediatric dosing (0.05mg/kg/day). Treatment may continue until 1 of the following:
- Renal transplantation; or
- Epiphyseal closure; or
- Covered height [Boys: 165.1cm (65 inches); Girls: 152.4cm (60 inches)]; or
- GV <2.5cm/year; and
- Adult Dosing: No proven benefit to continuing growth hormone treatment in adulthood.
- Continuation Approval:
- Member is still pre-transplant; and
- Medications and dosing should be appropriate; and
- Member should have had a recent office visit with new information regarding heights; and
- Member should be compliant; and
- Epiphyses are open; and
- GV should not be <2.5cm/year.
Short Stature Associated with Prader-Willi Syndrome (PWS) Approval Criteria:
- Initial Approval:
- Member must be 2 years of age or older; and
- Member must have a chromosome analysis confirming the diagnosis of PWS; and
- Growth hormone therapy must be prescribed by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); and
- Member’s growth velocity (GV) must be <10% on a GV curve for gender and age; and
- Member’s height must be ≥2.25 standard deviations (SD) below the mean for age and gender; and
- Member must have evidence of delayed bone age (undefined delay) and open epiphyses; and
- Member’s growth chart and parental heights must be provided; and
- If the form is completed, a growth chart is not required; and
- Parental heights are not always available; and
- Approval Length: 6 months if criteria met, compliant, and not needing to transition to adult dosing.
- Dosing:
- Pediatric Dosing: 0.24mg/kg/week. Treatment should continue until 1 of the following:
- Epiphyseal closure; or
- Covered height [Boys: 165.1cm (65 inches); Girls: 152.4cm (60 inches)]; or
- GV <2.5cm/year; and
- Adult Dosing: After attainment of adult height, adults with PWS may be considered for adult dosing if evidence is submitted documenting adult growth hormone deficiency [e.g., low insulin-like growth factor 1 (IGF-1) level and GH stimulation testing].
- Continuation Approval:
- Medications and dosing should be appropriate; and
- Member should have had a recent office visit with new information regarding heights provided; and
- Member should be compliant; and
- GV should not be <2.5cm/year; and
- For members on adult dosing, recent IGF-1 level and standard deviation score (SDS) should be submitted and SDS should be between -2 and +2.
Short Stature Associated with Turner Syndrome or 45X, 46XY Mosaicism Approval Criteria:
- Initial Approval:
- Member must be 2 years of age or older; and
- Member must have a chromosome analysis confirming the diagnosis of Turner Syndrome in females or 45X 46XY mosaicism in males; and
- Growth hormone therapy must be prescribed by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); and
- Approval Length: 6 months if criteria met and compliant. No adult dosing will be approved for this indication. Once epiphyses are closed, covered height has been met, or growth velocity (GV) is <2.5cm/year, therapy should be discontinued.
- Dosing:
- Pediatric Dosing: FDA approved dosing varies by product. See the “Growth Hormone Dosing” section above for current guideline-based dosing considerations. Treatment should continue until 1 of the following:
- Epiphyseal closure; or
- Covered height [Boys: 165.1cm (65 inches); Girls: 152.4cm (60 inches)]; or
- GV <2.5cm/year; and
- Adult Dosing: No proven benefit to continuing growth hormone treatment in adulthood.
- Continuation Approval:
- Medications and dosing should be appropriate; and
- Member should have had a recent office visit with new information regarding heights provided; and
- Member should be compliant; and
- Epiphyses should be open; and
- GV should not be <2.5cm/year.
Short Stature Associated with Noonan Syndrome Approval Criteria:
- Initial Approval:
- Member must be 2 years or older; and
- Member must have a chromosome analysis confirming the diagnosis of Noonan Syndrome; and
- Growth hormone therapy must be prescribed by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); and
- Approval Length: 6 months if criteria met and compliant. No adult dosing will be approved for this indication. Once epiphyses are closed, covered height has been met, or growth velocity (GV) is <2.5cm/year, therapy should be discontinued.
- Dosing:
- Pediatric Dosing: Standard dosing applies for members receiving pediatric dosing (up to 0.066mg/kg/day). Treatment should continue until 1 of the following:
- Epiphyseal closure; or
- Covered height [Boys: 165.1cm (65 inches); Girls: 152.4cm (60 inches)]; or
- GV <2.5cm/year.
- Adult Dosing: No proven benefit to continuing growth hormone treatment in adulthood.
- Continuation Approval:
- Medications and dosing should be appropriate; and
- Member should have had a recent office visit with new information regarding heights provided; and
- Member should be compliant; and
- Epiphyses should be open; and
- GV should not be <2.5cm/year.
Short Stature Associated with Short Stature Homeobox-Containing Gene (SHOX) Deficiency Approval Criteria:
- Initial Approval:
- Member must be 2 years or older; and
- Member must have a chromosome analysis confirming the diagnosis of SHOX deficiency; and
- Growth hormone therapy must be prescribed by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); and
- Member’s growth velocity (GV) must be <10% on a GV curve for gender and age; and
- Member’s height must be ≥2.25 standard deviations (SD) below the mean for age and gender; and
- Member must have evidence of delayed bone age (undefined delay) and open epiphyses; and
- Member’s growth chart and parental heights must be provided; and
- If the form is completed, a growth chart is not required; and
- Parental heights are not always available; and
- Member must have a normal endocrine screen; and
- Member must have no evidence of growth hormone deficiency or insensitivity, tumor activity, diabetes mellitus, history of impaired glucose tolerance, or other serious illness known to interfere with growth; and
- Approval Length: 6 months if criteria met and compliant. No adult dosing will be approved for this indication. Once epiphyses are closed, covered height has been met, or GV is <2.5cm/year, therapy should be discontinued.
- Dosing:
- Pediatric Dosing: Standard dosing applies for members receiving pediatric dosing (up to 0.05mg/kg/day). Treatment should continue until 1 of the following:
- Epiphyseal closure; or
- Covered height [Boys: 165.1cm (65 inches); Girls: 152.4cm (60 inches)]; or
- GV <2.5cm/year; and
- Adult Dosing: No proven benefit to continuing growth hormone treatment in adulthood.
- Continuation Approval:
- Medications and dosing should be appropriate; and
- Member should have had a recent office visit with new information regarding heights provided; and
- Member should be compliant; and
- Epiphyses should be open; and
- GV should not be <2.5cm/year.
Small for Gestational Age (SGA) Approval Criteria:
- Initial Approval:
- Member must be 2 years or age or older; and
- Documentation of birth weight <2,500 grams at gestational age of more than 37 weeks or birth weight or length below the 3rd percentile for gestational age; and
- Growth hormone therapy must be prescribed by an endocrinologist (or an advanced care practitioner with a supervising physician who is an endocrinologist); and
- Member’s growth velocity (GV) must be <10% on a GV curve for gender and age; and
- Member’s height must be ≥2.25 standard deviations (SD) below the mean for age and gender; and
- Member must have evidence of delayed bone age (undefined delay) and open epiphyses; and
- Member’s growth chart and parental heights must be provided; and
- If the form is completed, a growth chart is not required; and
- Parental heights are not always available; and
- Approval Length: 6 months if criteria met and compliant. No adult dosing will be approved for this indication. Once epiphyses are closed, covered height has been met, or GV is <2.5cm/year, therapy should be discontinued.
- Dosing:
- Pediatric Dosing: FDA approved dosing varies by product. See the “Growth Hormone Dosing” section above for current guideline-based dosing considerations. Treatment should continue until 1 of the following:
- Epiphyseal closure; or
- Covered height [Boys: 165.1cm (65 inches); Girls: 152.4cm (60 inches)]; or
- GV <2.5cm/year; and
- Adult Dosing: No proven benefit to continuing growth hormone treatment in adulthood.
- Continuation Approval:
- Medications and dosing should be appropriate; and
- Member should have had a recent office visit with new information regarding heights provided; and
- Member should be compliant; and
- Epiphyses should be open; and
- GV should not be <2.5cm/year.
Prior Authorization forms
PREFERRED
|
NON-Preferred
|
|
|
- Humatrope®
- Norditropin®
- Norditropin Nordiflex®
- Nutropin®
- Nutropin AQ®
- Omnitrope®
- Saizen®
- +Serostim®
- +Skytrofa (lonapegsomatropin-tcgd) (Ascendis) - Cartridge
- +Sogroya® (somapacitan-beco) (NovoNordisk) - Pens
- Tev-Tropin®
- +Zorbtive®
|
*Supplementally rebated product(s); tier structure based on supplemental rebate participation and/or National Average Drug Acquisition Costs (NADAC), Wholesale Acquisition Costs (WAC), or State Maximum Allowable Costs (SMAC).
+Additional approval criteria applies.
All products, other than Sogroya®, contain the identical 191 amino acid sequence found in pituitary-derived human growth hormone (hGH). For Sogroya®, 1 amino acid has been substituted and linked to an albumin-binding side chain.
Skytrofa® (Lonapegsomatropin-tcgd) Approval Criteria:
- Member must have a confirmed diagnosis of growth hormone deficiency (GHD) or panhypopituitarism meeting the initial growth hormone approval criteria (listed under “Initial Approval”) for the member’s specific diagnosis; and
- Member’s weight must be ≥11.5kg; and
- A patient-specific, clinically significant reason (beyond convenience) why the member cannot use all Tier-1 product(s) must be provided; and
- Prescriber must verify the member has been counseled on proper administration and storage of Skytrofa®; and
- Initial approvals will be for the 0.24mg/kg weekly dose, using the specific dose recommended in the Skytrofa® Prescribing Information; and
- Initial approvals will be for the duration of 6 months. For additional approval consideration:
- Dosing should be appropriate; and
- Member should have had a recent office visit with new information regarding heights provided; and
- Member should be compliant; and
- Growth velocity should not be <2.5cm/year; and
- Prescriber must verify member still has open epiphyses; and
- Skytrofa® will not be approved following epiphyseal closure. Skytrofa® is contraindicated in children with closed epiphyses.
Voxzogo™ (Vosoritide) Approval Criteria:
- Member must have an FDA approved diagnosis of achondroplasia; and
- Diagnosis must be confirmed by genetic testing identifying a pathogenic mutation in the FGFR3 gene; and
- Member must be 5 years of age or older; and
- Prescriber must verify member has open epiphyses; and
- The member’s baseline height and growth velocity (GV) must be provided; and
- Voxzogo™ must be prescribed by a geneticist, endocrinologist, or other specialist with expertise in the treatment of achondroplasia (or an advanced care practitioner with a supervising physician who is a geneticist, endocrinologist, or other specialist with expertise in the treatment of achondroplasia); and
- Member’s recent weight (taken within the past 3 weeks) must be provided in order to ensure appropriate dosing in accordance with the Voxzogo™ Prescribing Information; and
- Prescriber must verify the member or member’s caregiver has been counseled on proper administration and storage of Voxzogo™, including the need for adequate food and fluid intake prior to each dose; and
- A quantity limit of 30 vials per 30 days will apply; and
- Initial and subsequent approvals will be for the duration of 6 months. For additional approval consideration:
- Member’s current height must be provided and must demonstrate an improvement in GV from baseline; and
- Member’s recent weight must be provided and dosing must be appropriate; and
- Member should be compliant; and
- Prescriber must verify member still has open epiphyses; and
- Voxzogo™ will not be approved following epiphyseal closure.
