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

Initial criteria

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

Reauthorization criteria

• Patient previously approved for requested agent through plan’s PA process
• Patient has had clinical benefit (e.g., decreased symptom severity/frequency, reduction in tumor size, normalized IGF-1 or GH levels)
• Prescriber is a specialist in the relevant area or has consulted one
• Patient has no FDA labeled contraindications

Approval duration

6 months (All other plans); 12 months (BCBSIL renewal)