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Somavert (pegvisomant) — Blue Cross Blue Shield of New Mexico

acromegaly

Preferred products

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

Initial criteria

  • ONE of the following:
  • A. Continuation of therapy AND prescriber states patient has been treated with the requested agent within the past 180 days AND is at risk if therapy is changed OR
  • B. Diagnosis of acromegaly AND ALL of the following:
  • 1. ONE of the following: A. Inadequate response to surgical resection or pituitary radiation therapy (growth hormone and serum IGF‑1 above reference) OR B. Not a surgical candidate OR C. Will be used in combination with or following pituitary radiation therapy
  • 2. ONE of the following:
  • A. Currently treated and stable on requested agent [chart notes required] OR
  • B. Tried and had inadequate response to ONE preferred agent [chart notes required] AND ONE of the following: (dose/frequency to maximally tolerated; preexisting impaired glucose metabolism) OR
  • C. ONE preferred agent discontinued due to lack of efficacy/effectiveness/diminished effect/adverse event [chart notes required] OR
  • D. Intolerance or hypersensitivity to ONE preferred agent [chart notes required] OR
  • E. FDA labeled contraindication to ALL preferred agents [chart notes required] OR
  • F. ONE preferred agent expected to be ineffective, cause adherence barrier, worsen comorbid condition, limit function, or cause adverse reaction/physical or mental harm [chart notes required] OR
  • G. ONE preferred agent not in best interest of patient (medical necessity) [chart notes required] OR
  • H. Tried another drug in same class as ONE preferred agent and discontinued due to lack of efficacy/adverse event [chart notes required] OR
  • I. Currently using ONE preferred agent and requested agent will be used as add on (adjunctive) therapy OR
  • J. Supporting information exists for use of requested agent over ALL preferred agents
  • 3. Will NOT use requested agent in combination with Signifor LAR (pasireotide) OR
  • C. Another FDA labeled indication for requested agent and route of administration OR
  • D. Another indication supported in compendia for requested agent and route of administration
  • Prescriber is a specialist in, or has consulted with a specialist in, the area of diagnosis (e.g., endocrinologist, oncologist)
  • Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months