Ngenla (somatrogon-ghla) — CareFirst (Caremark)

Pediatric growth hormone deficiency (pediatric patients aged ≥ 3 years with growth failure due to inadequate secretion of endogenous growth hormone)

Initial criteria

Member is pediatric (age ≥ 3 years)
Member has a documented diagnosis of growth hormone deficiency as a neonate (e.g., hypoglycemia with random GH level, evidence of multiple pituitary hormone deficiency, chart notes, or magnetic resonance imaging [MRI] results) OR Member meets ALL of the following:
• Member has either of the following: (a) Two pretreatment pharmacologic provocative GH tests with both results demonstrating a peak GH level < 10 ng/mL OR (b) A documented pituitary or central nervous system (CNS) disorder (see Appendix) AND a pretreatment IGF‑1 level > 2 SD below the mean
• Member meets either of the following: (a) Pretreatment height is > 2 SD below the mean and 1‑year height velocity is > 1 SD below the mean OR (b) Pretreatment 1‑year height velocity is > 2 SD below the mean
• Epiphyses are open

Member is currently receiving the requested medication or another growth hormone product indicated for pediatric GH deficiency (e.g., Norditropin)
Epiphyses are open (confirmed by X‑ray or X‑ray not available)
Member’s growth rate is > 2 cm/year unless there is a documented clinical reason for lack of efficacy (e.g., treatment < 1 year, nearing final adult height, or late stages of puberty)

12 months