Somavert (pegvisomant) — Highmark
acromegaly
Preferred products
- generic octreotide acetate
Initial criteria
- age ≥ 18 years
- diagnosis of acromegaly (ICD-10: E22.0)
- high pretreatment insulin-like growth factor-1 (IGF-1) based on laboratory reference range
- member has had either inadequate or partial response to surgery or radiotherapy OR is not a candidate for surgery or radiotherapy
- therapeutic failure, contraindication, or intolerance to generic octreotide acetate
Reauthorization criteria
- Decreased IGF-1 from baseline OR Normalized IGF-1 from baseline
Approval duration
12 months