CurrentBlue Cross Blue Shield - NevadaPolicy N/A

Adult Growth Hormone Therapy — Prior Authorization (Somatropin, Skytrofa, Sogroya)

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.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyAdult Growth Hormone Therapy — Prior Authorization (Somatropin, Skytrofa, Sogroya)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with required documentation (biochemical confirmation or applicable testing) or the request will be returned.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥18age requirement for adult therapy

1 monthoff-therapy interval (pediatric→adult)

>10% WLHIV-associated wasting threshold

DEXA/BIAlean body mass measurement

Coverage Criteria

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Transition from pediatric growth hormone therapy

Covered when ALL of the following are met

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

from SOMATROPIN AGENTS - initial authorization

Transition from pediatric GH criteria: Member stopped growth hormone therapy for at least one month before reevaluation of the need for continued therapy.at least 1 month

from SOMATROPIN AGENTS - initial authorization

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

from SOMATROPIN AGENTS - initial authorization

Adult growth hormone deficiency — initiation and monitoring

Covered when ALL of the following are met

Adult GH deficiency diagnosis: Diagnosis of adult growth hormone deficiency with biochemical evidence or other applicable testing supporting the diagnosis; member is 18 years of age or older.

applies to somatropin, Skytrofa, Sogroya

Intracranial lesion/tumor assessment: Prescriber attests that necessary testing has been performed to ensure there are no expanding intracranial lesions or tumors prior to initiating growth hormone therapy; for reauthorization, prescriber attests to continued monitoring for intracranial tumor recurrence or progression as appropriate.

applies to all indications

Skytrofa (lonapegsomatropin) initial authorization

Covered when ALL of the following are met

Skytrofa initial: Diagnosis of growth failure due to growth hormone deficiency with biochemical evidence; member is 18 years of age or older; trial and failure of at least ONE preferred somatropin product or medical justification for not using preferred agents.

SKYTROFA (LONAPEGSOMATROPIN-TCGD) - Initial Authorization

Intracranial lesion/tumor assessment: Provider attests that they have performed all necessary testing to ensure there are no expanding intracranial lesions or tumors prior to initiating growth hormone therapy.

SKYTROFA (LONAPEGSOMATROPIN-TCGD) - Initial Authorization

Sogroya (somapacitan) initial authorization

Covered when ALL of the following are met

Sogroya initial: Diagnosis of adult growth hormone deficiency with biochemical evidence; member is 18 years of age or older; trial and failure of Skytrofa (lonapegsomatropin) OR prescriber provides medical justification to use Sogroya instead.

SOGROYA (SOMAPACITAN) - Initial Authorization

Intracranial lesion/tumor assessment: Prescriber attests that they have performed all necessary testing to ensure there are no expanding intracranial lesions or tumors prior to initiating growth hormone therapy.

SOGROYA (SOMAPACITAN) - Initial Authorization

HIV-associated wasting / cachexia

Covered when ALL of the following are met

HIV-associated wasting initial: Diagnosis of HIV-associated wasting or cachexia (Serostim only); quantitative measurement of lean body mass using DEXA or BIA; documentation of involuntary weight loss of >10% of baseline total body weight OR body cell mass <30% for initial approval; member has tried and failed at least one listed alternative (dronabinol, megestrol, anabolic steroids) unless none attempted or other reason provided.>10% weight loss; body cell mass <30%

SOMATROPIN AGENTS - initial authorization

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

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.

Provider Actions & Requirements

Prior Authorization

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

Prior Authorization

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

Prior Authorization

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

Documentation Required

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

OpenPayer

Adult Growth Hormone Therapy — Prior Authorization (Somatropin, Skytrofa, Sogroya)

Coverage Criteria

Coding & Thresholds

Provider Actions & Requirements

Background

Definitions