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Sogroya (somapacitan-beco) — Blue Cross Blue Shield of New Mexico

pediatric growth hormone deficiency or growth failure due to inadequate secretion of endogenous growth hormone

Preferred products

  • Humatrope (somatropin)
  • Norditropin FlexPro (somatropin)
  • Nutropin AQ Nuspin (somatropin)
  • Saizen (somatropin)
  • Saizenprep (somatropin)
  • Omnitrope (somatropin)
  • Serostim (somatropin)
  • Zomacton (somatropin)
  • Zorbtive (somatropin)

Initial criteria

  • Target long-acting GH agent approved when ONE of the following: diagnosis of growth hormone deficiency (GHD) or growth failure due to inadequate secretion of endogenous GH AND ONE of:
  • Patient has extreme short stature (height ≤ -3 SD), normal nutrition, significantly reduced IGF-1 and IGFBP-3 (≤ -2 SD), and delayed bone age (chart notes required)
  • OR BOTH of the following:
  • Pretreatment height >2 SD below mean for age/sex OR height velocity >2 SD below mean OR <10th percentile AND failed ≥2 GH stimulation tests (peak GH <10 mcg/L or abnormal) OR failed 1 stimulation test (peak GH <10 mcg/L or abnormal) AND pathology of CNS OR history of irradiation OR other pituitary hormone defects (MPHD) OR genetic defect (chart notes required)