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Somavert (pegvisomant) — Blue Cross Blue Shield of Texas

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

Preferred products

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

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 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 the following: (A) The patient had an inadequate response to surgical resection or pituitary radiation therapy as indicated by growth hormone and serum IGF-1 above reference ranges OR (B) The patient is not a candidate for surgical resection OR (C) The requested agent will be used in combination with or following pituitary radiation therapy AND
  • 2. ONE of the following:
  • A. The patient is currently being treated with the requested agent and is currently stable on it [chart notes required] OR
  • B. The patient has tried and had an inadequate response to ONE preferred agent [chart notes required] AND ONE of these: (1) preferred agent at maximally tolerated dose OR (2) preexisting impaired glucose metabolism OR
  • C. ONE preferred agent was discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required] OR
  • D. The patient has intolerance or hypersensitivity to ONE preferred agent [chart notes required] OR
  • E. The patient has an FDA labeled contraindication to ALL preferred agents [chart notes required] OR
  • F. ONE preferred agent is expected to be ineffective or cause major issues (ineffectiveness, barriers to adherence, worsen comorbidity, decrease function, cause adverse reaction or harm) [chart notes required] OR
  • G. ONE preferred agent not in patient's best interest by medical necessity [chart notes required] OR
  • H. The patient has tried another prescription drug in the same class as ONE preferred agent and discontinued due to lack of efficacy or adverse event [chart notes required] OR
  • I. The patient is currently using ONE preferred agent and the requested agent will be used as add-on therapy OR
  • J. There is information supporting use of the requested agent over ALL preferred agents AND
  • 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 compendia-supported indication 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.