CurrentAnthemPolicy N/A

Request for Prior Authorization - Adult (≥18 Years) Growth Hormone

Prior authorization form and requirements for initiating and continuing somatropin and related long-acting growth hormone agents for adult members (age ≥18) served by Anthem programs in Indiana.

Policy Summary

PayerAnthem

PolicyAdult (≥18) Growth Hormone Prior Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form with required clinical documentation, including biochemical evidence of adult growth hormone deficiency and trials of preferred somatropin products for long-acting agents.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+Member age covered (years)

TransitionTransition pathway

Skytrofa/SogroyaAgent-specific sections

Intracranial tumorProvider attestation

Coverage Criteria for Adult Growth Hormone Therapy

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Transition from pediatric GH: The member has reached adult height.

Cessation prior to reevaluation: Member stopped growth hormone therapy for at least one month before reevaluation of the need for continued therapy.

Prescriber determination: The prescriber has determined that the member will experience growth hormone deficiency into adulthood and would receive clinical benefit from continued growth hormone therapy.

Initial Authorization — Adult Growth Hormone Deficiency

Covered when ALL of the following are met

Age: Member is 18 years of age or older.

Diagnosis documentation: Biochemical evidence or other applicable testing supporting the diagnosis of adult growth hormone deficiency is provided.

Intracranial lesion exclusion: Prescriber attests that necessary testing has been performed to ensure there are no expanding intracranial lesions or tumors prior to initiating growth hormone therapy.

Skytrofa (lonapegsomatropin) Initial Authorization

Covered when ALL of the following are met

Diagnosis of growth failure due to growth hormone deficiency is documented.

Age: Member is 18 years of age or older.

Preferred-product trial: Trial and failure of at least ONE preferred somatropin product (or medical justification provided for not using preferred product).

Sogroya (somapacitan) Initial Authorization

Covered when ALL of the following are met

Diagnosis of adult growth hormone deficiency with biochemical evidence or other applicable testing.

Age: Member is 18 years of age or older.

Prior Skytrofa trial or justification: Either trial and failure of Skytrofa (supported by claims history or chart documentation) OR prescriber provides medical justification to use Sogroya over Skytrofa.

Reauthorization / Continuation Criteria

Covered when ALL of the following are met for reauthorization

Ongoing diagnosis: Member has a diagnosis of adult growth hormone deficiency and is continuing growth hormone therapy.

Monitoring for intracranial disease: Provider attests to continuing monitoring for intracranial tumor recurrence, progression of underlying disease, or malignant transformation of skin lesions, if appropriate.

Clinical benefit for HIV-associated wasting: For HIV-associated wasting, the member has demonstrated an increase in total body weight or lean body mass from treatment baseline (documentation required).

For requests for somatropin to treat HIV-associated wasting or cachexia, initial approval requires objective documentation. The prescriber must provide a quantitative measurement of lean body mass by DEXA or BIA and evidence of either involuntary weight loss of >10% of baseline total body weight or body cell mass <30% for initial approval. In addition, the member must have tried and failed at least one appetite-stimulating or anabolic agent (for example, dronabinol, megestrol, or anabolic steroids) unless a reasonable clinical justification is provided.

If the request is for a non-preferred agent, the prescriber must indicate the product-specific indication or provide a medical justification for use over a preferred agent on the form. For members transitioning from pediatric growth hormone therapy, requests that do not include the specified transition documentation (member has reached adult height; therapy ceased for at least one month for reevaluation; and prescriber determination that GH deficiency persists and continued therapy is clinically beneficial) will not meet the transition pathway requirements and should be documented accordingly.

Coding, Measurements, and Definitions

Involuntary weight loss — threshold

Threshold>10% of baseline total body weight

Measurement contextApplies to documentation of involuntary weight loss for HIV-associated wasting or cachexia initial approval

Supporting methodDocumented in clinical records or form as part of required diagnostic documentation

Body cell mass — threshold

Threshold<30% body cell mass

Measurement contextUsed as alternate criterion to >10% involuntary weight loss for HIV-associated wasting initial approval

Supporting requirementRequires prior trial and failure of appetite stimulants/therapeutic agents (dronabinol, megestrol, anabolic steroids) before somatropin approval

Transition from pediatric growth hormone therapy — definition

DefinitionMember has reached adult height

Cessation requirementMember stopped growth hormone therapy for at least one month before reevaluation of the need for continued therapy

Prescriber determinationPrescriber has determined the member will experience growth hormone deficiency into adulthood and would receive clinical benefit from continued therapy

HIV-associated wasting or cachexia — criteria

Required quantitative measurementDual energy X-ray absorptiometry (DEXA) or bioelectric impedance analysis (BIA) to measure lean body mass

Weight threshold>10% involuntary weight loss from baseline total body weight (qualifies for initial approval)

Body cell mass thresholdBody cell mass <30% (alternate qualifying criterion)

Prior therapy requirementDocumentation of trial and failure of at least one appetite stimulant/therapeutic agent (dronabinol, megestrol, anabolic steroids) prior to somatropin approval

Provider Requirements and Prior Authorization Actions

Prior Authorization

Prior Authorization Required

Prior authorization required for somatropin agents for adults. Separate initial and reauthorization sections apply — complete all required fields and documentation for each request.

Initial and reauthorization requests must use the prescribing provider form and include all sections completed.
Fax PA requests to: 844-864-7860 (retail) or 888-209-7838 (medical injectable).
Retroactive PA: mark box and include dates of service for retroactive eligibility requests (submit separately if dates of service >30 days prior).

Prior Authorization

Skytrofa PA requirements

Skytrofa-specific PA requirements: patient must be ≥18 years old, have biochemical or testing documentation supporting adult GHD, and have trial and failure of at least one preferred somatropin product (support with chart documentation or dates of use). If no preferred trial, provide medical justification. Provider must attest no expanding intracranial lesions/tumors prior to initiating therapy and sign the form.

Diagnosis of adult growth hormone deficiency: biochemical evidence or applicable testing required.
Member is 18 years of age or older — must be checked.
Trial and failure of at least ONE preferred somatropin product: indicate Yes/No and provide chart documentation or dates of use; if No, include medical justification.
Provider attestation re: intracranial lesions/tumors and prescriber signature required.

Step Therapy

Preferred-product trial required for long-acting agents

Preferred-product trial requirement for long-acting somatropin agents (Skytrofa and Sogroya). For Sogroya, indicate trial and failure of Skytrofa (supported by claims history or chart documentation) or provide medical justification for use of Sogroya instead.

Sogroya initial requests must show either trial and failure of Skytrofa (claims or chart) or include prescriber medical justification.
Chart documentation or claims history acceptable to demonstrate prior trial/failure.
Prescriber justification must be specific about why preferred agent(s) are unsuitable.

Documentation Required

Required diagnostic documentation

Required diagnostic documentation for adult growth hormone deficiency: provide biochemical evidence or other applicable testing that supports the diagnosis. For HIV-associated wasting/cachexia (Serostim), provide quantitative lean body mass (DEXA or BIA) and documentation of involuntary weight loss >10% or body cell mass <30% for initial approval.

Biochemical evidence or applicable testing supporting adult GHD must be included.
HIV-associated wasting/cachexia: DEXA or BIA results and weight-loss/body cell mass data required.
Include dates and results of relevant tests in the submission.

Documentation Required

Demographic and clinical measurements

Prescriber must complete demographic and clinical measurement fields and sign the form. Include patient identifiers, prescriber details, return fax/phone, and indicate if requesting retroactive PA with dates of service. Provide current, 3-month, and 6-month height and weight measurements as requested on the form.

Complete: patient name, Medicaid number, date of birth.
Complete: prescriber's name, specialty, NPI, IN license number, prescriber signature, return fax and phone number.
Mark box if requesting retroactive PA and list dates of service for retroactive eligibility.
Provide anthropometrics: current height and weight, 3-month prior height/weight, 6-month prior height/weight.
Form will be returned if all sections are not completed.

Denial Risk

Incomplete submission risk

Incomplete submissions will be returned; ensure all sections of the prescribing provider form are fully completed to avoid denial or delay.

All sections must be completed or the request will be returned.
Providers contracted through ACO/PMG/IPA should follow their group's authorization and claims processes and contact their group administrator or Anthem network representative with questions.

Background and Scope

This prior authorization form supports initiation and continuation of growth hormone therapy for adults, including members transitioning from pediatric therapy, established adult growth hormone deficiency, and HIV-associated wasting/cachexia. For adult growth hormone deficiency the form requires biochemical evidence or other applicable testing to document the diagnosis and a prescriber attestation that necessary testing has been performed to exclude expanding intracranial lesions before initiating therapy. For transitioning members the form requires documentation that the member has reached adult height, stopped GH therapy for at least one month for reevaluation, and that the prescriber has determined the member will experience GH deficiency into adulthood and would benefit clinically from continued therapy.

Policy Summary

PayerAnthem

PolicyAdult (≥18) Growth Hormone Prior Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

OpenPayer

Request for Prior Authorization - Adult (≥18 Years) Growth Hormone

Coverage Criteria for Adult Growth Hormone Therapy

Coding, Measurements, and Definitions

Provider Requirements and Prior Authorization Actions

Background and Scope

Policy Revision History