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Somavert (pegvisomant) — Blue Cross Blue Shield of Illinois

other compendia-supported indications

Preferred products

  • lanreotide deep subcutaneous injection (Somatuline Depot generic equivalent)
  • octreotide gluteal intramuscular injection

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 (not starting on samples) within the past 180 days AND is at risk if therapy is changed
  • OR B. The patient has a diagnosis of acromegaly AND ALL of the following:
  • 1. ONE of the following: (A) The patient had an inadequate response to surgical resection or pituitary radiation therapy as indicated by growth hormone and serum IGF-1 that are above the reference ranges OR (B) The patient is not a candidate for surgical resection OR (C) The requested agent will be used in combination with or following pituitary radiation therapy
  • 2. ONE of the following:
  • A. The patient is currently being treated with the requested agent and is stable (chart notes required)
  • B. The patient has tried and had an inadequate response to ONE preferred agent [chart notes required] AND ONE of the following: 1. The dose and/or frequency of the preferred agent has been increased to the maximally tolerated dose OR 2. The patient has preexisting impaired glucose metabolism
  • C. ONE preferred agent was discontinued due to lack of efficacy or an adverse event (chart notes required)
  • D. The patient has an intolerance or hypersensitivity to ONE preferred agent (chart notes required)
  • E. The patient has an FDA labeled contraindication to ALL preferred agents (chart notes required)
  • F. ONE preferred agent is expected to be ineffective or cause significant issues based on known characteristics (chart notes required)
  • G. ONE preferred agent is not in the best interest of the patient based on medical necessity (chart notes required)
  • H. The patient has tried another drug in the same pharmacologic class or with the same mechanism and that drug was discontinued due to lack of efficacy or adverse event (chart notes required)
  • I. The patient is currently using ONE preferred agent and the requested agent will be used as adjunct therapy
  • J. There is information in support of use of the requested agent over ALL preferred agents
  • 3. 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 (e.g., endocrinologist, oncologist) or has consulted with a specialist
  • AND The patient does NOT have any FDA labeled contraindications