Mycapssa — Medical Mutual

Initial criteria

• The medication is prescribed by or in consultation with an endocrinologist
• The patient has previously responded to and tolerated treatment with octreotide or lanreotide
• The patient had a baseline (prior to initiation of any somatostatin analog [Signifor LAR, Somatuline Depot, Mycapssa], dopamine agonist [bromocriptine, cabergoline] or Somavert) IGF-1 level above the upper limit of normal (ULN) for age and gender per the laboratory’s standard reference values
• The patient is at least age ≥ 18 years

Reauthorization criteria

• Documentation of response to therapy with Mycapssa is required for continuation

Approval duration

1 year initial, 1 year reauth