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

other FDA labeled indications for the requested agent and route of administration

Initial criteria

  • 1. ONE of the following:
  • A. The requested agent is eligible for continuation of therapy AND the following: the prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) 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 the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
  • 3. The patient does NOT have any FDA labeled contraindications to the requested agent.
  • Alternate path for members in Ohio (Fully Insured or HIM Shop plans):
  • A. The patient does NOT have any FDA labeled contraindications to the requested agent AND
  • B. ONE of the following: (1) the patient has another FDA labeled indication for the requested agent and route of administration OR (2) the patient has another indication supported in compendia OR (3) the prescriber has submitted TWO articles from major peer-reviewed journals supporting the proposed use as generally safe and effective.

Reauthorization criteria

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

Approval duration

6–12 months