Sandostatin (octreotide acetate) — United Healthcare

Initial criteria

• Diagnosis of one of the following:
• Neuroendocrine tumor (carcinoid tumors, islet cell tumors, gastrinomas, glucagonomas, insulinomas, lung tumors, somatostatinomas, tumors of the pancreas, GI tract, lung, thymus, adrenal glands, vasoactive intestinal polypeptidomas [VIPomas])
• OR
• All of the following:
• Diagnosis of pheochromocytoma OR paraganglioma OR well-differentiated grade 3 neuroendocrine tumor
• AND
• Disease is locally unresectable OR metastatic

Reauthorization criteria

• Patient does not show evidence of progressive disease while on Sandostatin therapy
• OR
• Documentation of positive clinical response (e.g., suppression of severe diarrhea, flushing, etc.) to Sandostatin therapy

Approval duration

12 months