Xermelo — Medical Mutual

Initial criteria

• Patient is age ≥ 18 years
• Xermelo will be used in combination with a long-acting somatostatin analog (SSA) therapy (e.g. Somatuline Depot, Sandostatin LAR)
• Patient has been using a stable dose of a long-acting SSA (e.g. Somatuline Depot, Sandostatin LAR) for at least 3 consecutive months
• Prior to starting Xermelo, patient continues to have at least 4 bowel movements per day while on long-acting SSA therapy
• Medication is prescribed by or in consultation with an endocrinologist, oncologist, or gastroenterologist

Reauthorization criteria

• Patient is age ≥ 18 years
• Xermelo will continue to be used in combination with a long-acting somatostatin analog (SSA) therapy (e.g. Somatuline Depot, Sandostatin LAR)
• Patient has had a beneficial response to therapy with Xermelo per the prescribing physician
• Patient has not developed severe constipation
• Medication is prescribed by or in consultation with an endocrinologist, oncologist, or gastroenterologist

Approval duration

1 year initial, 1 year reauth