Sogroya (somapacitan-beco) — CareFirst (Caremark)

Adult growth hormone deficiency

Preferred products

ANY of the following:
1. Member had 2 pretreatment pharmacologic provocative GH tests with both demonstrating deficient GH responses defined as:
• Insulin tolerance test (ITT) peak GH ≤ 5 ng/mL OR
• Macrilen peak GH < 2.8 ng/mL OR
• Glucagon stimulation test peak GH ≤ 3.0 ng/mL in BMI ≤ 30 kg/m2 and high pretest probability of GHD or BMI < 25 kg/m2 OR
• Glucagon stimulation test peak GH ≤ 1.0 ng/mL in BMI ≥ 25 kg/m2 and low pretest probability of GHD or BMI > 30 kg/m2
AND pretreatment IGF-1 level 0 to 2 SD below mean for age and gender
2. Member had 1 pretreatment pharmacologic GH test demonstrating deficient GH response per above and pretreatment IGF-1 level > 2 SD below mean for age/gender
3. Organic hypothalamic-pituitary disease (e.g., suprasellar mass with surgery and cranial irradiation) with ≥ 3 documented pituitary hormone deficiencies and pretreatment IGF-1 level > 2 SD below mean for age/gender
4. Genetic or congenital structural hypothalamic-pituitary defects
5. Childhood-onset GH deficiency with congenital abnormality of CNS, hypothalamus, or pituitary

Member currently receiving the requested medication or another growth hormone product (e.g., Norditropin) for adult GH deficiency
ANY of the following:
• Current IGF-1 level not elevated for age/gender
• Organic hypothalamic-pituitary disease with ≥ 3 pituitary hormone deficiencies
• Genetic or congenital structural hypothalamic-pituitary defects
• Childhood-onset GH deficiency with congenital abnormality of CNS, hypothalamus, or pituitary

12 months