Prior Authorization Criteria for Approval

Initial Evaluation

Somavert will be approved when BOTH of the following are met:

1. The patient has a diagnosis of acromegaly AND ONE of the following:
   1. There is evidence of a claim that the patient is currently being treated with the requested medication within the past 90 days
      OR
   2. The prescriber states the patient is currently being treated with the requested medication AND provided clinical justification to support that the patient is at risk if therapy is changed
      OR
   3. BOTH of the following:
      1. ONE of the following:
         1. The patient is not a candidate for surgical resection or pituitary radiation therapy
            OR
         2. The requested medication is for adjunctive therapy with pituitary radiation therapy
            OR
         3. The patient had an inadequate response to surgery or pituitary radiation therapy as indicated by serum IGF-1 levels that are above the reference range
            AND
      2. ONE of the following:
         1. The patient has tried and had an inadequate response to octreotide or Somatuline Depot (lanreotide)
            OR
         2. The patient has an intolerance or hypersensitivity to octreotide or Somatuline Depot (lanreotide)
            OR
         3. The patient has an FDA labeled contraindication to octreotide or Somatuline Depot (lanreotide)
            AND
2. The requested dose is within FDA labeled dosing for the requested indication

Length of Approval: 6 months

Renewal Evaluation

Somavert will be approved when ALL of the following are met:

1. The patient has been previously approved for the requested medication through the plan’s Prior Authorization criteria
   AND
2. The patient has a diagnosis of acromegaly
   AND
3. The patient has had clinical benefit with the requested medication
   AND
4. The requested dose is within FDA labeled dosing for the requested indication

Length of Approval: 12 months