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

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

Reauthorization criteria

• 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

Approval duration

12 months