Growth Hormones
PDL Reference Documents
- Growth Hormone in Adults - Apr 06, 2023
- Growth Hormone PA Update - Dec 01, 2022
- Growth Hormones Class Update/New Drug Evaluation - Dec 02, 2021
- Growth Hormones - Jun 03, 2021
- Growth Hormone - Nov 29, 2018
- Growth Hormone Literature Scan - Sep 28, 2017
- Growth Hormones - Sep 29, 2016
- Growth Hormones - Sep 24, 2015
- Growth Hormones - Sep 23, 2014
- Class Scan: Growth Hormone - Sep 26, 2013
- Class Scan: Growth Hormones - Sep 27, 2012
PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 73362001001 | SKYTROFA | lonapegsomatropin-tcgd | CARTRIDGE | 11 mg | N | Y | PA Document |
| 73362001002 | SKYTROFA | lonapegsomatropin-tcgd | CARTRIDGE | 11 mg | N | Y | PA Document |
| 73362001101 | SKYTROFA | lonapegsomatropin-tcgd | CARTRIDGE | 13.3 mg | N | Y | PA Document |
| 73362001102 | SKYTROFA | lonapegsomatropin-tcgd | CARTRIDGE | 13.3 mg | N | Y | PA Document |
| 73362000301 | SKYTROFA | lonapegsomatropin-tcgd | CARTRIDGE | 3 mg | N | Y | PA Document |
| 73362000302 | SKYTROFA | lonapegsomatropin-tcgd | CARTRIDGE | 3 mg | N | Y | PA Document |
| 73362000401 | SKYTROFA | lonapegsomatropin-tcgd | CARTRIDGE | 3.6 mg | N | Y | PA Document |
| 73362000402 | SKYTROFA | lonapegsomatropin-tcgd | CARTRIDGE | 3.6 mg | N | Y | PA Document |
| 73362000501 | SKYTROFA | lonapegsomatropin-tcgd | CARTRIDGE | 4.3 mg | N | Y | PA Document |
| 73362000502 | SKYTROFA | lonapegsomatropin-tcgd | CARTRIDGE | 4.3 mg | N | Y | PA Document |
| 73362000601 | SKYTROFA | lonapegsomatropin-tcgd | CARTRIDGE | 5.2 mg | N | Y | PA Document |
| 73362000602 | SKYTROFA | lonapegsomatropin-tcgd | CARTRIDGE | 5.2 mg | N | Y | PA Document |
| 73362000701 | SKYTROFA | lonapegsomatropin-tcgd | CARTRIDGE | 6.3 mg | N | Y | PA Document |
| 73362000702 | SKYTROFA | lonapegsomatropin-tcgd | CARTRIDGE | 6.3 mg | N | Y | PA Document |
| 73362000801 | SKYTROFA | lonapegsomatropin-tcgd | CARTRIDGE | 7.6 mg | N | Y | PA Document |
| 73362000802 | SKYTROFA | lonapegsomatropin-tcgd | CARTRIDGE | 7.6 mg | N | Y | PA Document |
| 73362000901 | SKYTROFA | lonapegsomatropin-tcgd | CARTRIDGE | 9.1 mg | N | Y | PA Document |
| 73362000902 | SKYTROFA | lonapegsomatropin-tcgd | CARTRIDGE | 9.1 mg | N | Y | PA Document |
| 00169203011 | SOGROYA | somapacitan-beco | PEN INJCTR | 10 mg/1.5 mL (6.7 mg/mL) | N | Y | PA Document |
| 00169203711 | SOGROYA | somapacitan-beco | PEN INJCTR | 15 mg/1.5 mL (10 mg/mL) | N | Y | PA Document |
| 00169203511 | SOGROYA | somapacitan-beco | PEN INJCTR | 5 mg/1.5 mL (3.3 mg/mL) | N | Y | PA Document |
| 00069050501 | NGENLA | somatrogon-ghla | PEN INJCTR | 24 mg/1.2 mL (20 mg/mL) | N | Y | PA Document |
| 00069050502 | NGENLA | somatrogon-ghla | PEN INJCTR | 24 mg/1.2 mL (20 mg/mL) | N | Y | PA Document |
| 00069052001 | NGENLA | somatrogon-ghla | PEN INJCTR | 60 mg/1.2 mL (50 mg/mL) | N | Y | PA Document |
| 00069052002 | NGENLA | somatrogon-ghla | PEN INJCTR | 60 mg/1.2 mL (50 mg/mL) | N | Y | PA Document |
| 00781300407 | OMNITROPE | somatropin | CARTRIDGE | 10 mg/1.5 mL (6.7 mg/mL) | N | Y | PA Document |
| 00002814801 | HUMATROPE | somatropin | CARTRIDGE | 12 mg (36 unit) | N | Y | PA Document |
| 00013264681 | GENOTROPIN | somatropin | CARTRIDGE | 12 mg/mL (36 unit/mL) | Y | Y | PA Document |
| 00002814901 | HUMATROPE | somatropin | CARTRIDGE | 24 mg (72 unit) | N | Y | PA Document |
| 00781300107 | OMNITROPE | somatropin | CARTRIDGE | 5 mg/1.5 mL (3.3 mg/mL) | N | Y | PA Document |
| 00013262681 | GENOTROPIN | somatropin | CARTRIDGE | 5 mg/mL (15 unit/mL) | Y | Y | PA Document |
| 00002814701 | HUMATROPE | somatropin | CARTRIDGE | 6 mg (18 unit) | N | Y | PA Document |
| 00169770521 | NORDITROPIN FLEXPRO | somatropin | PEN INJCTR | 10 mg/1.5 mL (6.7 mg/mL) | Y | Y | PA Document |
| 50242007401 | NUTROPIN AQ NUSPIN | somatropin | PEN INJCTR | 10 mg/2 mL (5 mg/mL) | N | Y | PA Document |
| 00169770821 | NORDITROPIN FLEXPRO | somatropin | PEN INJCTR | 15 mg/1.5 mL (10 mg/mL) | Y | Y | PA Document |
| 50242007601 | NUTROPIN AQ NUSPIN | somatropin | PEN INJCTR | 20 mg/2 mL (10 mg/mL) | N | Y | PA Document |
| 00169770321 | NORDITROPIN FLEXPRO | somatropin | PEN INJCTR | 30 mg/3 mL (10 mg/mL) | Y | Y | PA Document |
| 00169770421 | NORDITROPIN FLEXPRO | somatropin | PEN INJCTR | 5 mg/1.5 mL (3.3 mg/mL) | Y | Y | PA Document |
| 50242007501 | NUTROPIN AQ NUSPIN | somatropin | PEN INJCTR | 5 mg/2 mL (2.5 mg/mL) | N | Y | PA Document |
| 00013264901 | GENOTROPIN | somatropin | SYRINGE | 0.2 mg/0.25 mL | Y | Y | PA Document |
| 00013264902 | GENOTROPIN | somatropin | SYRINGE | 0.2 mg/0.25 mL | Y | Y | PA Document |
| 00013265002 | GENOTROPIN | somatropin | SYRINGE | 0.4 mg/0.25 mL | Y | Y | PA Document |
| 00013265102 | GENOTROPIN | somatropin | SYRINGE | 0.6 mg/0.25 mL | Y | Y | PA Document |
| 00013265202 | GENOTROPIN | somatropin | SYRINGE | 0.8 mg/0.25 mL | Y | Y | PA Document |
| 00013265302 | GENOTROPIN | somatropin | SYRINGE | 1 mg/0.25 mL | Y | Y | PA Document |
| 00013265402 | GENOTROPIN | somatropin | SYRINGE | 1.2 mg/0.25 mL | Y | Y | PA Document |
| 00013265502 | GENOTROPIN | somatropin | SYRINGE | 1.4 mg/0.25 mL | Y | Y | PA Document |
| 00013265602 | GENOTROPIN | somatropin | SYRINGE | 1.6 mg/0.25 mL | Y | Y | PA Document |
| 00013265702 | GENOTROPIN | somatropin | SYRINGE | 1.8 mg/0.25 mL | Y | Y | PA Document |
| 00013265802 | GENOTROPIN | somatropin | SYRINGE | 2 mg/0.25 mL | Y | Y | PA Document |
| 55566190101 | ZOMACTON | somatropin | VIAL | 10 mg | N | Y | PA Document |
| 44087000401 | SEROSTIM | somatropin | VIAL | 4 mg | N | Y | PA Document |
| 44087000407 | SEROSTIM | somatropin | VIAL | 4 mg | N | Y | PA Document |
| 44087000501 | SEROSTIM | somatropin | VIAL | 5 mg | N | Y | PA Document |
| 44087000507 | SEROSTIM | somatropin | VIAL | 5 mg | N | Y | PA Document |
| 55566180101 | ZOMACTON | somatropin | VIAL | 5 mg | N | Y | PA Document |
| 00781400436 | OMNITROPE | somatropin | VIAL | 5.8 mg | N | Y | PA Document |
| 00781401471 | OMNITROPE | somatropin | VIAL | 5.8 mg | N | Y | PA Document |
| 44087000601 | SEROSTIM | somatropin | VIAL | 6 mg | N | Y | PA Document |
| 44087000607 | SEROSTIM | somatropin | VIAL | 6 mg | N | Y | PA Document |