Somavert (pegvisomant) — Blue Cross Blue Shield of Montana
other FDA labeled indications
Preferred products
- lanreotide deep subcutaneous injection (Somatuline Depot generic equivalent)
- octreotide gluteal intramuscular injection
Initial criteria
- ONE of the following: (A) Requested agent eligible for continuation of therapy AND prescriber states patient has been treated with requested agent (not samples) within past 180 days AND is at risk if therapy is changed OR (B) Patient has diagnosis of acromegaly AND ALL of: (1) ONE of: inadequate response to surgical resection or pituitary radiation therapy as shown by GH and IGF-1 above reference range OR not a candidate for surgery OR requested agent used in combination with or following pituitary radiation therapy AND (2) ONE of: currently stable on requested agent OR tried and had inadequate response to ONE preferred agent (lanreotide or octreotide) and relevant medical rationale (dose maxed, glucose metabolism, intolerance, contraindication, etc., as listed in policy items A–J) OR other listed circumstances (intolerance, contraindications, clinical characteristics, add-on use, literature support)
- Patient will NOT use requested agent in combination with Signifor LAR (pasireotide)
- Patient may have another FDA labeled indication or compendia supported indication
- Prescriber is a specialist in endocrinology/oncology or has consulted
- No FDA labeled contraindications