Mycapssa (octreotide acetate) — Blue Cross Blue Shield of Illinois

acromegaly

Initial criteria

ONE of the following:
A. The requested agent is eligible for continuation of therapy AND the following: the prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 180 days AND is at risk if therapy is changed
OR B. The patient has a diagnosis of acromegaly AND BOTH of the following: (1) The patient has responded to and tolerated treatment with octreotide or lanreotide AND (2) The patient will NOT be using the requested agent in combination with Signifor LAR (pasireotide)
OR C. The patient has another FDA labeled indication for the requested agent and route of administration
OR D. The patient has another indication that is supported in compendia for the requested agent and route of administration
AND The prescriber is a specialist in the area of the patient's diagnosis (e.g., endocrinologist, oncologist) or has consulted with a specialist
AND The patient does NOT have any FDA labeled contraindications to the requested agent

The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
AND The patient has had clinical benefit with the requested agent (e.g., decrease in symptom severity/frequency, reduction in tumor size, normalized IGF-1 and/or growth hormone levels)
AND The prescriber is a specialist in the area of the patient’s diagnosis or has consulted with a specialist
AND The patient does NOT have any FDA labeled contraindications to the requested agent

12 months