Sandostatin — CareFirst (Caremark)
Acromegaly
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