Mycapssa (octreotide acetate) — Blue Cross Blue Shield of New Mexico

acromegaly

Initial criteria

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

Patient previously approved for requested agent through plan’s PA process
Patient has had clinical benefit with the requested agent (e.g., decreased symptom severity/frequency, tumor size reduction, normalized IGF‑1 and/or growth hormone levels)
Prescriber is a specialist in, or has consulted with a specialist in, the patient's diagnosis area (e.g., endocrinologist, oncologist)
Patient does NOT have any FDA labeled contraindications to the requested agent

12 months