Sogroya — Cigna

Growth Hormone Deficiency in a Child

Initial criteria

Patient must have a diagnosis of growth hormone deficiency confirmed by at least one of the following: (1) at least one growth hormone stimulation test performed with levodopa, insulin-induced hypoglycemia, arginine, clonidine, or glucagon and the peak growth hormone response < 10 ng/mL; OR (2) deficiency in at least one other pituitary hormone (adrenocorticotropic hormone, thyroid-stimulating hormone, gonadotropin deficiency counted as one, or prolactin); OR (3) imaging triad of ectopic posterior pituitary and pituitary hypoplasia with abnormal pituitary stalk; OR (4) patient has had a hypophysectomy.
The medication has been prescribed by or in consultation with an endocrinologist.
OR Patient has multiple pituitary hormone deficiencies and meets one of the following: (a) three or more pituitary hormone deficiencies; OR (b) one growth hormone stimulation test with a peak growth hormone response < 10 ng/mL; AND the medication prescribed by or in consultation with an endocrinologist.

Patient is currently receiving Sogroya or switching from another growth hormone agent (established on therapy ≥ 10 months) AND meets one of the following: (i) patient age < 12 years and height has increased by ≥ 2 cm/year in the most recent year; OR (ii) patient age ≥ 12 years and < 18 years and height has increased by ≥ 2 cm/year in the most recent year AND epiphyses are open; OR (iii) patient age ≥ 18 years and height has increased by ≥ 2 cm/year in the most recent year AND epiphyses are open AND mid-parental height has not been attained.

1 year