Sandostatin (octreotide acetate) — United Healthcare

Initial criteria

• Diagnosis of thymoma or thymic carcinoma
• AND
• One of the following:
• Used as a second-line therapy for unresectable locally advanced disease OR solitary metastasis/ipsilateral pleural metastasis OR extrathoracic metastatic disease
• OR
• All of the following:
• Used as first-line therapy for potentially resectable locally advanced disease OR potentially resectable solitary metastasis/ipsilateral pleural metastasis OR consideration following surgery for solitary metastasis/ipsilateral pleural metastasis OR medically inoperable/unresectable solitary metastasis/ipsilateral pleural metastasis OR extrathoracic metastatic disease OR postoperative treatment for thymoma after R2 resection OR preoperative systemic therapy for surgically resectable disease if R0 resection uncertain
• AND
• Patient is unable to tolerate first-line combination regimens

Reauthorization criteria

• Patient does not show evidence of progressive disease while on Sandostatin therapy

Approval duration

12 months