Mycapssa — CareFirst (Caremark)

Initial criteria

• Member has a high pretreatment IGF-1 level for age and/or gender based on the laboratory reference range
• Member had an inadequate or partial response to surgery or radiotherapy OR there is a clinical reason why the member has not had surgery or radiotherapy
• For Mycapssa requests, member has previously responded to and tolerated treatment with octreotide or lanreotide

Reauthorization criteria

• Member’s IGF-1 level has decreased or normalized since initiation of therapy

Approval duration

12 months