CommercialPrior AuthMedium impact
Growth Hormone (Revised)
Humana·Endocrinology, Pediatrics, Internal Medicine·Commercial
Effective date
Aug 28, 2024
We identified it
Jun 25, 2026
Summary
Humana revised its Growth Hormone pharmacy coverage policy effective August 28, 2024, updating clinical criteria for prior authorization across 15 growth hormone products. The policy maintains coverage for pediatric indications (GH deficiency, SGA, SHOX deficiency, chronic renal insufficiency, Prader-Willi, Turner's, and Noonan syndromes) and adds adult coverage criteria. Billing teams must verify prior authorization requirements are in place for all growth hormone claims and ensure documentation meets the updated clinical criteria.
Action Required
By September 30, 2024: Billing and authorization teams must review and update prior authorization workflows in billing system for all 15 affected growth hormone products (Humatrope, Norditropin, Saizen, Zomacton, Omnitrope, Nutropin AQ, Genotropin, HumatroPen, Skytrofa, Sogroya, Ngenla). Ensure system reflects updated clinical criteria including: (1) for pediatric GH deficiency—requirement for bone age delay documentation, growth velocity measurements, and two GH stimulation tests (or one test if high clinical suspicion); (2) for adult GH deficiency—specific clinical criteria per policy; (3) transition coverage requirements for members previously treated in childhood. Communicate updated criteria to providers via bulletin. Update prior authorization request forms to include checklist of required documentation (growth curves, lab values, test results per indication). Train authorization staff on new adult coverage criteria. Verify claims processing rejects any prescriptions without prior authorization. Failure to implement may result in claim denials or payment delays.