Sandostatin (octreotide acetate) — United Healthcare

Initial criteria

• Diagnosis of acromegaly
• AND
• One of the following:
• Inadequate response to surgical resection OR pituitary irradiation OR dopamine agonist (e.g., bromocriptine, cabergoline) therapy
• OR
• Not a candidate for surgical resection OR pituitary irradiation OR dopamine agonist (e.g., bromocriptine, cabergoline) therapy

Reauthorization criteria

• Documentation of positive clinical response to Sandostatin therapy

Approval duration

12 months