CurrentColorado Rocky Mountain Health PlansPolicy N/A

Human Growth Hormone (somatropin) — Washington Prior Authorization Request Form

Washington prior authorization request form for human growth hormone (somatropin) therapies used for pediatric and adult growth hormone deficiency, short bowel syndrome, HIV-associated wasting/cachexia, and related indications; intended for prescribers and pharmacies submitting PA to Colorado Rocky Mountain Health Plans for Washington (Apple Health) members.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyHuman Growth Hormone (somatropin) — Washington Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete the Washington prior authorization form and submit indication-specific documentation to request coverage for somatropin.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleindications listed

24 hoursmin review time

866-940-7328fax

800-310-6826phone

Coverage Criteria for Somatropin (Human Growth Hormone)

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Initial Pediatric Therapy

Covered when ALL of the following apply as documented on the form for children/adolescents (<18):

pediatric_epiphyses: Patient's epiphyses are not closed (radiograph of the wrist and hand) AND patient has not reached final height

question 7

pediatric_diagnoses

congenital_GHD: Congenital GHD represented by acute hypoglycemia with low serum GH
question 8
GHD_height_velocity: Height below 3rd percentile OR height below 5th percentile with growth velocity below 25th percentile for ≥1 year
question 8
GHD_tests: At least two GH stimulation tests below reference OR one stimulation test below reference plus IGF-1 and IGFBP-3 below normal OR IGF-1/IGFBP-3 severely low (<-2 SD) with delayed bone age OR GHD with additional pituitary hormone deficiencies
question 8

Continuation Therapy — Pediatric

Covered when ALL of the following apply for continuation in children:

pediatric_continuation: Request is for continuation and patient has shown a response to growth hormone therapy (increase in height or increase in height velocity)

question 9

Initial Adult Therapy

Covered when ONE OR MORE of the following adult GHD criteria are documented:

adult_multiple_pituitary: Documentation of three or more pituitary hormone deficiencies with a low IGF-1 level (<-2 SD)

question 10

adult_childhood_onset: Documented childhood-onset GHD or GHD due to pituitary/hypothalamic disease, pituitary surgery, cranial radiation, traumatic brain injury, or other condition affecting pituitary function

question 10

adult_clinical_features: Documented clinical features of GHD (e.g., osteopenia, increased cardiovascular risk, decreased quality of life)

question 10

adult_low_IGF1: Low IGF-1 level (specified as <0 SD in one line; severe low referenced as <-2 SD elsewhere)

Continuation Therapy — Adult

Covered when ANY of the following responses to therapy are documented for continuation in adults:

adult_continuation_responses: Normalization of IGF-1 OR improvement in body composition (e.g., increased bone density, favorable lipolysis changes)

question 11

Short Bowel Syndrome

Covered when documented specialized nutritional support has been optimized prior to somatropin:

sbs_nutrition_optimization: Patient is currently on specialized nutritional support optimized for protein, calorie, and fluid intake for at least two weeks>=2 weeks

question 12

HIV-associated Wasting/Cachexia

Covered when the following are documented for HIV-associated wasting/cachexia:

hiv_appetite_stimulant_trial: Patient has been treated with an appetite stimulant (dronabinol or megestrol) that was ineffective, contraindicated, or not tolerated

question 13

hiv_prior_somatropin: Document prior somatropin exposure if applicable and state duration in weeks

question 14

hiv_continuation_response: For continuation, patient has shown clinical benefit (increase in muscle mass and weight)

question 15

Therapies that do not meet the form’s specified diagnostic criteria or that lack required supporting documentation may be excluded from coverage. The authorization form requires indication-specific evidence such as confirmation that pediatric patients have open epiphyses (radiograph of wrist and hand) and diagnosis-specific findings (e.g., percentile thresholds, growth velocity, results of GH stimulation testing, IGF-1/IGFBP-3 values, or documentation of syndromic indications). Requests that fail to document these required diagnostic elements or objective test results consistent with the listed criteria may not satisfy medical necessity for human growth hormone therapy.

Completed chart notes and baseline assessments are required with the prior authorization request. The form explicitly states that prescriber signature, prescriber specialty, date, and supporting chart documentation (including baseline and current height/weight measurements and relevant clinical notes) must be submitted. Requests submitted without these materials are subject to delay or denial for failure to meet documentation requirements.

Key Diagnostic Thresholds & Coding-related Values

Predicted adult height threshold

Predicted adult height threshold (SGA/idiopathic)Expected adult height based on bone age less than 63 inches for males and less than 59 inches for females

Source contextQuestion asks if adult height based on bone age is expected to be below these thresholds

UseApplies to idiopathic short stature and SGA-related growth failure assessments on the PA form

Pediatric height percentiles

Height below 3rd percentileFor Growth Hormone Deficiency: height below the 3rd percentile (>2 SDs below mean)

Height below 5th percentile with low velocityHeight below the 5th percentile with growth velocity below the 25th percentile for ≥1 year

Height below 10th percentileFor Turner, Noonan, or SHOX deficiency: height below the 10th percentile for age and sex

IGF-1 abnormality thresholds (adult)

IGF-1 severely low (adult criteria)IGF-1 below -2 SD may be used for severe deficiency in some criteria

Low IGF-1 (adult supportive finding)Low IGF-1 level defined on the form as <0 standard deviation score

Context of useLow IGF-1 is listed as one of the documented supportive findings for adult GHD on the PA form

GH stimulation test thresholds

Macimorelin thresholdSubnormal response defined as macimorelin <2.8 ng/mL

Insulin tolerance test (ITT) thresholdSubnormal response defined as ITT <5 ng/mL

Glucagon stimulation test (GST) thresholdSubnormal response defined as GST <3 ng/mL

Pediatric GHD diagnostic criteria

Short stature percentile/velocity criteriaPediatric GHD criteria include height <3rd percentile OR height <5th percentile with growth velocity below the 25th percentile for ≥1 year

GH stimulation test abnormalitiesAt least two GH stimulation tests below reference OR one stimulation test below reference plus low IGF-1 and IGFBP-3; severe low IGF-1/IGFBP-3 (<-2 SD) with delayed bone age also qualifies

Congenital GHDCongenital GHD evidenced by acute hypoglycemia with low serum GH levels is included

Other supportive findingsDelayed bone age or GHD with additional pituitary hormone deficiencies can support diagnosis

What Providers Must Submit and Actions Required

Prior Authorization

Prior Authorization Required

Prior authorization required — Prior authorization is required for human growth hormone. Complete the Human Growth Hormone/Washington Prior Authorization Request Form and fax to 866-940-7328. Allow at least 24 hours for review; for questions call 800-310-6826.

Complete entire form; allow at least 24 hours for review
Fax number: 866-940-7328
Questions: 800-310-6826

Step Therapy

Preferred Product Trial Requirement

Preferred product trial requirement — For requests for non-preferred growth hormone products, document prior trial(s) of one or more preferred growth hormone medications on the Apple Health Preferred Drug List (AHPDL) that were ineffective, contraindicated, or not tolerated, including medication name(s) and duration(s) of trial. If a preferred product was not tried, provide an explanation (for example, not FDA‑approved for the requested indication).

List each preferred medication and duration of trial on the PA form or indicate reason a preferred product was not tried

Documentation Required

Required Submission Materials

Required submission materials — A completed prior authorization form with prescriber signature and specialty, the required chart notes, and baseline assessments (weight, height, dates, diagnosis-specific documentation and stimulation test results where applicable) must be submitted with the request.

Completed Human Growth Hormone PA form with prescriber signature and specialty
Baseline weight and height with dates (pre-treatment and current)
Diagnosis-specific documentation (e.g., stimulation test results, IGF-1/IGFBP-3 levels, radiograph confirmation of open epiphyses for children)
Chart notes supporting indication and prior therapy trials

Denial Risk

Missing Documentation

Missing documentation — Failure to include the completed PA form, prescriber signature/specialty, required chart notes, baseline assessments, or documentation of preferred product trials may delay or prevent approval.

Omitted chart notes or baseline assessments can delay or result in denial
Lack of documentation of preferred product trials or justification for not trying preferred agents may affect approval

OpenPayer

Human Growth Hormone (somatropin) — Washington Prior Authorization Request Form

Coverage Criteria for Somatropin (Human Growth Hormone)

Key Diagnostic Thresholds & Coding-related Values

What Providers Must Submit and Actions Required

Background