Sogroya — Medica

Initial criteria

• Endocrinologist must certify that growth hormone therapy is not being prescribed for anti-aging therapy or to enhance athletic ability or for body building
• Patient has a diagnosis of growth hormone deficiency that is ONE of the following: childhood onset OR adult onset that results from growth hormone deficiency alone or multiple hormone deficiencies (hypopituitarism) resulting from 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) Patient (adult or transition adolescent) has known perinatal insults or congenital or genetic defects OR (ii) Patient has three or more of the following pituitary hormone deficiencies prior to hormone replacement therapy (adrenocorticotropic hormone, thyroid-stimulating hormone, gonadotropin deficiency, prolactin) AND low age/gender adjusted serum insulin-like growth factor-1 prior to growth hormone therapy AND other causes of low IGF-1 excluded OR (iii) Patient meets growth hormone stimulation testing criteria as outlined (for adult or transition adolescent)
• Medication prescribed by or in consultation with an endocrinologist

Approval duration

1 year