Sogroya — Cigna

Initial criteria

• The endocrinologist must certify growth hormone therapy is not being prescribed for anti-aging, athletic enhancement, or bodybuilding.
• Patient must have a diagnosis of growth hormone deficiency that is either (i) childhood onset, OR (ii) adult onset resulting from growth hormone deficiency alone or multiple hormone deficiencies (hypopituitarism) due to pituitary disease, hypothalamic disease, pituitary surgery, cranial radiation therapy, tumor treatment, traumatic brain injury, or subarachnoid hemorrhage.
• Patient meets at least one of the following: (i) known perinatal insults or congenital/genetic defects; OR (ii) has or had three or more pituitary hormone deficiencies (adrenocorticotropic hormone, thyroid-stimulating hormone, gonadotropin deficiency, prolactin) prior to replacement therapy AND serum insulin-like growth factor-1 below the lower limit of normal AND other causes of low IGF-1 excluded; OR (iii) has had a negative response to at least one growth hormone stimulation test (insulin tolerance, glucagon, Macrilen, or arginine test per specified peak response thresholds and BMI criteria).
• The medication prescribed by or in consultation with an endocrinologist.

Approval duration

1 year