Adult Growth Hormone Therapy — Prior Authorization (Somatropin, Skytrofa, Sogroya)
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - Nevada policy alerts
Know when Blue Cross Blue Shield - Nevada releases new policies or updates existing guidance.
Monitor payer policy activity
Prior authorization form and requirements for initiation and reauthorization of somatropin and long-acting growth hormone products for adults (≥18 years), including transition from pediatric therapy and HIV-associated wasting, for members served by Anthem/Blue Cross Blue Shield plans in Indiana.
No material clinical or coverage changes in this revision.
Coverage Criteria
Transition from pediatric growth hormone therapy
Covered when ALL of the following are met
from SOMATROPIN AGENTS - initial authorization
from SOMATROPIN AGENTS - initial authorization
from SOMATROPIN AGENTS - initial authorization
Adult growth hormone deficiency — initiation and monitoring
Covered when ALL of the following are met
applies to somatropin, Skytrofa, Sogroya
applies to all indications
Skytrofa (lonapegsomatropin) initial authorization
Covered when ALL of the following are met
SKYTROFA (LONAPEGSOMATROPIN-TCGD) - Initial Authorization
SKYTROFA (LONAPEGSOMATROPIN-TCGD) - Initial Authorization
Sogroya (somapacitan) initial authorization
Covered when ALL of the following are met
SOGROYA (SOMAPACITAN) - Initial Authorization
SOGROYA (SOMAPACITAN) - Initial Authorization
HIV-associated wasting / cachexia
Covered when ALL of the following are met
SOMATROPIN AGENTS - initial authorization
SOMATROPIN AGENTS - reauthorization
The prior authorization form specifies that the diagnosis of HIV-associated wasting or cachexia is limited to Serostim for this indication. Other somatropin products are not implied to be indicated for HIV-associated wasting unless the prescriber documents a product-specific indication or medical justification on the form.
For requests involving HIV-associated wasting, the form requires quantitative measurement of lean body mass (using DEXA or BIA) and documentation of either involuntary weight loss >10% of baseline total body weight or body cell mass <30% for initial approval. The prescriber must also document trials of listed alternatives (dronabinol, megestrol, anabolic steroids) or explain why none were tried.
Coding & Thresholds
Provider Actions & Requirements
Prior Authorization Required
Prior authorization is required for initiation and reauthorization of adult growth hormone (somatropin) products, including Skytrofa and Sogroya. Transition rules apply for members moving from pediatric therapy to adult therapy; ensure prior authorization is obtained before continued treatment.
- Prior authorization required for initiation and reauthorization of somatropin agents (including Skytrofa and Sogroya)
- Transition rules apply for members transitioning from pediatric growth hormone therapy
Skytrofa - Product-specific Initial Authorization Requirements
Skytrofa (lonapegsomatropin) initial authorization requires documentation of adult growth hormone deficiency, that the member is 18 years or older, and trial and failure of at least one preferred somatropin product (supported by claims history or chart documentation). If no prior trial, provide medical justification explaining why preferred agents are unsuitable.
- Member is 18 years of age or older
- Trial and failure of at least ONE preferred somatropin product (provide chart documentation or dates of use)
- If no trial, provide medical justification for why preferred agent(s) are unsuitable
- Provider attestation that necessary testing has been performed to exclude expanding intracranial lesions or tumors prior to initiating therapy
Sogroya - Product-specific Initial Authorization Requirements
Sogroya (somapacitan) initial authorization requires documentation of adult growth hormone deficiency and that the member is 18 years of age or older. If requesting Sogroya instead of Skytrofa, documentation of trial and failure of Skytrofa (claims or chart) is requested or medical justification for using Sogroya over Skytrofa must be provided.
- Diagnosis of adult growth hormone deficiency requires biochemical evidence or other applicable testing
- Member is 18 years of age or older
- Trial and failure of Skytrofa (supported by claims history or chart documentation) OR documented medical justification for using Sogroya over Skytrofa
- Provider attestation that necessary testing has been performed to exclude expanding intracranial lesions or tumors prior to initiating therapy
Form Completion & Documentation Requirements
Form completion and documentation requirements: The prescribing provider must complete the prior authorization form in full; incomplete forms will be returned. Documentation required for adult growth hormone deficiency includes biochemical evidence or other applicable testing supporting the diagnosis. For HIV-associated wasting (Serostim only), provide quantitative lean body mass measurement (DEXA or BIA) and documentation of involuntary weight loss >10% of baseline total body weight or body cell mass <30% for initial approval.
- Prescribing provider must complete the form in full; incomplete requests will be returned. Fax to Prior Authorization of Benefits Center at 844-864-7860 (retail) or 888-209-7838 (medical injectable).
- Documentation for adult growth hormone deficiency: biochemical evidence or other applicable testing supporting the diagnosis
- For HIV-associated wasting (Serostim only): quantitative measurement of lean body mass via DEXA or BIA, and involuntary weight loss >10% of baseline total body weight OR body cell mass <30% for initial approval
Background
This form is intended to support clinical assessment and documentation for adult patients with growth hormone deficiency, including those transitioning from pediatric therapy and those with HIV-associated wasting. It guides the prescriber to provide biochemical evidence or other applicable testing to confirm adult growth hormone deficiency and to attest that necessary evaluation for intracranial lesions or tumors has been performed prior to initiating therapy.
The form also captures key treatment-planning information such as whether the request is for a preferred versus non-preferred agent, product-specific indications or medical justification for non-preferred use, and dosing regimen details needed for the prior authorization review.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.