CurrentCignaPolicy IP0375

Skytrofa (lonapegsomatropin) coverage for growth hormone deficiency

Cigna Coverage Policy (IP0375) defines prior authorization requirements, medical necessity criteria, reauthorization, preferred product/step requirements, exclusions, and authorization durations for Skytrofa (lonapegsomatropin) for pediatric and adult growth hormone deficiency across multiple plan types.

Policy Summary

PayerCigna

PolicySkytrofa (lonapegsomatropin) coverage for growth hormone deficiency

Policy CodePolicy IP0375

Change TypePreferred product requirement updates and policy statement/criteria revisions

Effective Date

Next Review Date

Key ActionSubmit prior authorization with required documentation (diagnostic evaluations, stimulation test results, auxologic data, IGF-1 levels, and plan-specific preferred product trial/intolerance information); reviews are directed to a clinician for verification.

POLICY UPDATE CHANGES

Removed preferred product requirements from the Standard, Value and Legacy formularies.

Updated Individual and Family plan preferred product requirements.

Updated the Employer Plans preferred product requirements.

Policy Statement updated to include clinician (pharmacist or nurse) for verification of criteria; added 'at least' to requirement for two GH stimulation tests < 10 ng/mL; added continuation criterion related to mid-parental height not obtained; added adult/transition adolescent criteria and documentation requirements.

12 monthsInitial approval duration

12 monthsReauthorization duration