Sandostatin LAR Depot — CareFirst (Caremark)

Initial criteria

• Severe secretory diarrhea when anti-microbial (e.g., ciprofloxacin or metronidazole) or anti-motility agents (e.g., loperamide or diphenoxylate and atropine) have become ineffective

Reauthorization criteria

• Member is experiencing clinical benefit as evidenced by improvement or stabilization in clinical signs and symptoms since initiation of therapy

Approval duration

12 months