Subject: Specialty Quantity Limit Sogroya 4287-H P2025

Drug

SOGROYA  (somapacitan-beco)

Policy:

Program Description

The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. The recommended dosing parameters for all FDA-approved indications fall within the standard limits. Coverage of an additional quantity may be reviewed on a case-by-case basis upon request.

Covered Quantities

Medication	Standard Limit
Sogroya (somapacitan-beco) 5 mg/1.5 mL single-patient-use prefilled pen	4 pens per 28 days
Sogroya (somapacitan-beco) 10 mg/1.5 mL single-patient-use prefilled pen	4 pens per 28 days
Sogroya (somapacitan-beco) 15 mg/1.5 mL single-patient-use prefilled pen	4 pens per 28 days

FDA-recommended Dosing

Adult Growth Hormone Deficiency

Initial dose

• 5 mg once weekly
• Patients aged 65 years and older: 1 mg once weekly
• Women receiving oral estrogen: 2 mg once weekly

Dose increase

• Increase the weekly dosage every 2 to 4 weeks by approximately 0.5 mg to 1.5 mg until the desired response is achieved. Titrate the dosage based on clinical response and serum insulin-like growth factor-1 (IGF-1) concentrations drawn 3 to 4 days after the prior dose. Decrease the dosage as necessary based on adverse reactions and/or serum IGF-1 concentrations above the age- and sex-specific normal range.
• Maximum dose: 8 mg once weekly
• Dose adjustments may be needed for patients with moderate hepatic impairment.

Pediatric Growth Hormone Deficiency

0.16 mg/kg based on actual body weight once weekly. Individualize dosage for each patient based on growth response.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Sogroya [package insert]. Plainsboro, NJ: Novo Nordisk, Inc; April 2023.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

June 07, 2025