Health Law Daily Wrap Up, COVERAGE—S.D. Fla.: ERISA dispute over Florida Blue's coverage of Skytrofa growth-hormone can proceed, (Jul 31, 2026)

By Jeffrey H. Brochin, J.D.

There are genuine disputes over whether Skytrofa is excluded or covered under the plan’s guidelines.

A federal District Court in Forida has denied the Motion for Judgement on the Pleadings filed by Blue Cross and Blue Shield of Florida, Inc. (Administrator or Florida Blue), in a lawsuit brought by an Insured who was the guardian of a minor Beneficiary. The Administrator had denied the Insured’s request for a growth-hormone medication for the pediatric Beneficiary despite the Beneficiary’s medical provider informing the Administrator than only the growth hormone medication Skytrofa was suitable for the Beneficiary’s pediatric growth hormone deficiency (GHD). Although the Administrator argued thar it was “indisputable that the operative Plan expressly excludes the prescription drug Skytrofa,” the court found that the alleged exclusion of Skytrofa was not clear on the face of the Complaint as alleged by the Administrator nor as provided for in the Administrator’s own documents (Mosse v. Blue Cross and Blue Shield of Florida, Inc., No. 1:25-cv-22687-RKA (S.D. Fla. July 27, 2026)).

The Beneficiary suffered from GHD as well as multiple skin issues which required the growth hormone medication Skytrofa, a once-weekly GH injection indicated for pediatric GHD. The family and physician proactively determined that Skytrofa was the only Growth Hormone Therapy suitable for the Beneficiary to prevent foreseeable skin complications, rather than wait for the child to suffer reactions to daily injections. The Insured therefore requested that the Administrator approve a Skytrofa 9.1 MG Cartridge Prescription.

In a letter dated April 21, 2025, the Administrator denied the request based on the Handbook/Certificate of Coverage or Drug Lists, and further stated that the request was not approved because the product/service was not covered under the Insured’s pharmacy plan. In a letter dated April 23, 2025, the Administrator issued a second denial letter. After the Insured’s request for a Second Level Appeal Review (with a specific request that a meaningful review be provided and proper appeal be conducted in accordance with ERISA guidelines), was similarly denied—and noted that the ‘outcome on April 23, 2025, was the final level of appeal'—the Insured filed the instant lawsuit. Presently before the court was the Administrator’s Motion for Judgement on the Pleadings.

Exclusion of coverage. The Administrator claimed that it was ‘indisputable that the operative Plan expressly excludes the prescription drug Skytrofa’ and in support of their Motion, the Administrator referenced the Plan’s Benefit Booklet which the Insured had appended to the Complaint. The booklet incorporated a Medication Guide which in turn hyperlinked to a ‘Medications Not Covered List’ (List) which included ‘Skytrofa injection.’ The Administrator therefore concluded that the Plan’s exclusion of Skytrofa injections was clear on the face of the Complaint and the incorporated documents.

The Insured countered that the Coverage Guidelines—which the Booklet also incorporated—cited the drug agents Norditropin, Genotropin, and Omnitrope as the preferred growth hormone products, but that in switching to the preferred agent from a non-preferred agent, certain criteria could be used to determine medical necessity. The Insured read those provisions as providing that Skytrofa is ‘expressly covered when the preferred brands are not suitable for the Patient,’ and that because Skytrofa was a “medically necessary prescription” for the Beneficiary, the Administrator’s denial of treatment violated the policy provisions, the Medication Guide, and the Coverage Guidelines. He further pointed out that Florida Blue’s own coverage guidelines stated that ‘non preferred agents are covered under certain circumstances.’ (Emphasis in original.)

The Administrator responded to the Insured’s argument by contending that it was premised on a misreading of the Plan and incorporated Medication Guide, explaining that ‘covered Pharmacy Benefits’ included tiers of covered prescriptions, including ‘Covered Generic Prescriptions’ as Tier 1, ‘Covered Preferred’ Prescriptions as Tier 2, and ‘Covered Non-Preferred’ Medications as Tier 3. And, that directly below that provision was the aforementioned ‘Medications that are not covered,’ including the List that includes Skytrofa. Based on those two points, the Administrator concluded that for this particular Plan, Skytrofa was not a Non-Preferred, Tier 3 Prescription that could be covered under the Coverage Guideline in certain circumstances; rather, Skytrofa was in fact a wholly excluded drug because it was on the List of drugs that are not covered by the Plan.

Genuine factual dispute. The court addressed these competing assertions noting that ‘the Insured might well be misreading the Plan, but we cannot say that the Administrator’s two arguments to that effect impel a legal conclusion based on those facts.’

Drawing all reasonable inferences in favor of the Insured, the court found that the Complaint did plead enough facts from which it could reasonably be inferred that the Beneficiary might qualify for Skytrofa under the Coverage Guidelines. Daily GH shots containing preservatives could irritate or inflame the skin with each dose, whereas Skytrofa’s once-weekly, preservative-free injection was less likely to irritate or cause allergic dermatitis and minimized repeated insult to the skin and avoided chemicals known to cause contact sensitivities. Accordingly, those facts made Skytrofa the safer option dermatologically, and the family and physician had proactively determined that Skytrofa was the only Growth Hormone Therapy suitable for the Beneficiary to prevent foreseeable skin complications.

Based on the foregoing, the court denied Florida Blue’s Motion for Judgement on the Pleadings.

The case is No. 1:25-cv-22687-RKA.

Judge: Altman, R.

Attorneys: Maria T. Santi (Health and Medicine Law Firm) for Matias Mosse. Andrew Reay (Troutman Pepper Locke LLP) for Blue Cross and Blue Shield of Florida, Inc. d/b/a Florida Blue.

Companies: Blue Cross and Blue Shield of Florida, Inc. d/b/a Florida Blue

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