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

acromegaly

Initial criteria

1. ONE of the following:
A. Continuation of therapy: The prescriber states the patient has been treated with the requested agent (not samples) within the past 180 days AND is at risk if therapy is changed OR
B. The patient has a diagnosis of acromegaly AND BOTH of the following:
1. The patient has responded to and tolerated treatment with octreotide or lanreotide AND
2. 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
2. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist, oncologist) or has consulted with a specialist AND
3. The patient does NOT have any FDA labeled contraindications to the requested agent

1. Patient was previously approved for the requested agent through the plan’s prior authorization process AND
2. Patient has had clinical benefit (e.g., decrease in symptom severity/frequency, reduction in tumor size, normalized IGF-1 and/or growth hormone levels) AND
3. Prescriber is a specialist in the area of the diagnosis (e.g., endocrinologist, oncologist) or has consulted with a specialist AND
4. Patient does NOT have any FDA labeled contraindications to the requested agent

12 months