Pharmacy Prior Authorization Criteria

Somavert (pegvisomant)

Indications for Prior Authorization

Somavert (pegvisomant)

• For diagnosis of Acromegaly
  Indicated for the treatment of acromegaly in patients who have had an inadequate response to surgery or radiation therapy, or for whom these therapies are not appropriate. The goal of treatment is to normalize serum insulin-like growth factor-1 (IGF-1) levels.

Criteria

Somavert

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of acromegaly
AND
• One of the following: [2]
• Inadequate response to one of the following:
• Surgery
• Radiation therapy
• Dopamine agonist (e.g., bromocriptine, cabergoline) therapy
OR
• Not a candidate for all of the following:
• Surgery
• Radiation therapy
• Dopamine agonist (e.g., bromocriptine, cabergoline) therapy
AND
• One of the following: [2]
• Inadequate response, contraindication, or intolerance to a somatostatin analog (e.g., octreotide, Somatuline [lanreotide])
OR
• Clinical rationale provided for preferred treatment with pegvisomant (e.g., comorbid diabetes mellitus is present with acromegaly)
AND
• Prescribed by or in consultation with an endocrinologist

Somavert

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy (such as biochemical control, decrease or normalization of IGF-1 levels)

P & T Revisions

2024-11-04, 2023-11-20, 2022-11-22, 2021-10-27, 2021-09-27, 2021-05-26, 2021-05-25, 2020-10-26, 2019-12-02

References

1. Somavert Prescribing Information. Pharmacia & Upjohn Company LLC. New York, NY. July 2023.
2. Katznelson L, Laws ER Jr, Melmed S, Molitch ME, Murad MH, Utz A, Wass JA. Acromegaly: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2014;99(11):3933-51.

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Revision History

• 2024-11-04: 2024 annual review: no criteria changes, background updates.
• 2023-11-20: 2023 annual review: Updated step through generic octreotide.
• 2022-11-22: Annual review - update initial authorization duration from 12 weeks to 12 months.
• 2021-10-27: Annual Review
• 2021-09-27: Addition of EHB formulary to guideline, no changes to criteria
• 2021-05-26: Addition of EHB formulary to guideline, no changes to criteria
• 2021-05-25: Addition of EHB formulary to guideline, no changes to criteria
• 2020-10-26: Annual Review: removed drug name from reauth
• 2019-12-02: 2019 Annual Review: updated background & references

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