Xermelo (telotristat ethyl tablets – Lexicon) — Cigna

Preferred products

• Somatuline Depot (lanreotide subcutaneous injection)
• Sandostatin LAR Depot (octreotide subcutaneous injection)

Initial criteria

• Patient has been on a long-acting somatostatin analog therapy for at least 3 consecutive months; AND
• While on a long-acting somatostatin analog therapy (prior to starting Xermelo), the patient continues to have at least four bowel movements per day; AND
• Xermelo will be used concomitantly with a long-acting somatostatin analog therapy

Reauthorization criteria

• Patient is continuing to take Xermelo concomitantly with a long-acting somatostatin analog therapy for carcinoid syndrome diarrhea

Approval duration

1 year