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Skytrofa — Cigna

Growth Hormone Deficiency in a Child or Adolescent

Initial criteria

  • Patient has congenital hypopituitarism AND meets BOTH of the following (a and b):
  • a) Patient meets at least ONE of the following [(1), (2), or (3)]:
  • (1) Patient meets BOTH of the following [(i) and (ii)]:
  • (i) Patient has had one growth hormone stimulation test with any of the following agents: levodopa, insulin-induced hypoglycemia, arginine, clonidine, or glucagon; AND
  • (ii) The peak growth hormone response to at least one test is < 10 ng/mL; OR
  • (2) Patient has a deficiency in at least one other pituitary hormone (adrenocorticotropic hormone, thyroid-stimulating hormone, gonadotropin [luteinizing hormone and/or follicle stimulating hormone deficiency counted as one deficiency], or prolactin); OR
  • (3) Patient has the imaging triad of ectopic posterior pituitary and pituitary hypoplasia with abnormal pituitary stalk; AND
  • b) The medication has been prescribed by or in consultation with an endocrinologist; OR
  • Patient has multiple pituitary hormone deficiencies and meets BOTH of the following (a and b):
  • a) Patient meets at least ONE of the following [(1) or (2)]:
  • (1) Patient has three or more of the following pituitary hormone deficiencies: somatropin (growth hormone), adrenocorticotropic hormone, thyroid-stimulating hormone, gonadotropin (luteinizing hormone and/or follicle stimulating hormone deficiency counted as one deficiency), and prolactin; OR
  • (2) Patient meets BOTH of the following [(i) and (ii)]:
  • (i) Patient has had one growth hormone stimulation test with any of the following agents: levodopa, insulin-induced hypoglycemia, arginine, clonidine, or glucagon; AND
  • (ii) The peak growth hormone response to at least one test is < 10 ng/mL; AND
  • The medication has been prescribed by or in consultation with an endocrinologist; OR
  • Patient has had a hypophysectomy (surgical removal of pituitary gland)

Reauthorization criteria

  • Patient is currently receiving Skytrofa or is switching to Skytrofa from another Growth Hormone Agent (therapy ≥ 10 months), AND meets ONE of the following:
  • i. Patient age < 12 years: height increased by ≥ 2 cm/year in most recent year; OR
  • ii. Patient age ≥ 12 years and < 18 years: height increased by ≥ 2 cm/year in most recent year AND epiphyses are open; OR
  • iii. Patient age ≥ 18 years: height increased by ≥ 2 cm/year in most recent year AND epiphyses are open AND mid-parental height not attained

Approval duration

1 year