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Somavert (pegvisomant) — Blue Cross Blue Shield of Oklahoma

acromegaly

Preferred products

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

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 ALL of the following:
  • 1. ONE of:
  • A. Inadequate response to surgical resection or pituitary radiation therapy (growth hormone and IGF-1 above reference ranges) OR
  • B. Not a candidate for surgical resection OR
  • C. Will be used in combination with or following pituitary radiation therapy AND
  • 2. ONE of:
  • A. Currently treated and stable on the requested agent [chart notes required] OR
  • B. Tried and had inadequate response to ONE preferred agent [chart notes required] AND ONE of:
  • 1. Dose/frequency of preferred agent maximized OR
  • 2. Preexisting impaired glucose metabolism OR
  • C. ONE preferred agent discontinued due to lack of efficacy/effectiveness/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 or cause harm/barrier/adverse effects [chart notes required] OR
  • G. ONE preferred agent not in best interest based on medical necessity [chart notes required] OR
  • H. Tried another drug in same class as preferred agent with lack of efficacy/adverse event [chart notes required] OR
  • I. Currently using ONE preferred agent and the requested agent will be used as adjunctive therapy OR
  • J. Information supports use of requested agent over ALL preferred agents OR
  • 3. 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. Prescriber is a specialist in the area of diagnosis (e.g., endocrinologist, oncologist) or has consulted with a specialist AND
  • 3. Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months