Somavert — Medical Mutual
Acromegaly
Initial criteria
- Patient is age ≥ 18 years; AND
- Agent is prescribed by or in consultation with an endocrinologist; AND
- Patient has had an inadequate response to or is ineligible for surgery, radiation, or bromocriptine OR is experiencing negative effects due to tumor size (e.g. optic nerve compression); AND
- Patient had a baseline IGF-1 level above the upper limit of normal (ULN) for age and gender per the laboratory’s standard reference values (baseline refers to prior to the initiation of any somatostatin analog, dopamine agonist, or Somavert); AND
- Patient has tried and failed or has contraindication(s) to the use of generic octreotide subcutaneous injection; AND
- Patient is NOT currently using Lanreotide or Octreotide
Reauthorization criteria
- Response to therapy is required for continuation of therapy
Approval duration
1 year initial, 1 year reauth