A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Drug Category: Endocrine/metabolic and Gastrointestinal Agents
Medication Class/Individual Agents: Acromegaly Agents, Carcinoid Syndrome Agents, and Somatostatin Analogs
I. Prior-Authorization Requirements
Carcinoid Syndrome Agents |
Clinical Notes |
||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.
1 Katznelson L, Laws ER Jr, Melmed S, Molitch ME, Murad MH, Utz A, et al. Acromegaly: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2014 Nov;99(11):3933-51. 2 Katznelson L, Atkinson JL, Cook DM, Ezzat SZ, Hamrahian AH, Miller KK et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of acromegaly–2011 update. Endocr Pract. 2011 Jul-Aug;17 Suppl 4:1-44. |
||||||||||||||
Growth Hormone Receptor Antagonists |
|||||||||||||||
|
|||||||||||||||
Somatostatin Analogs |
|||||||||||||||
|
| # | This designates a brand-name drug with FDA “A”-rated generic equivalents. Prior authorization is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent. |
II. Therapeutic Uses
FDA-approved, for example:
- Acromegaly (Signifor LAR, Somavert)
- Carcinoid syndrome diarrhea (Xermelo)
Note: the above list may not include all FDA-approved indications.
III. Evaluation Criteria for Approval
Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.
- All PA requests must include clinical diagnosis, drug name, dose, and frequency.
- A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
- Additional criteria may apply, depending upon the member’s condition and requested medication (see below).
Signifor LAR
- Documentation of the following is required:
- appropriate diagnosis; and
- member is under the care of an endocrinologist; and
- one of the following:
- member has persistent or recurring disease following surgery and/or radiation; or
- member is not a candidate for surgery; and
- one of the following:
- inadequate response or adverse reaction to one somatostatin analog that does not require PA; or
- contraindication to somatostatin analogs; and
- one of the following:
- member has moderate-to-severe disease symptoms; or
- member has mild disease and one of the following:
- inadequate response or adverse reaction to one dopamine analog (e.g., cabergoline, bromocriptine) in combination with a somatostatin analog; or
- adverse reaction to one somatostatin analog that does not require PA; or
- contraindication to dopamine analogs.
Somavert
- Documentation of the following is required:
- appropriate diagnosis; and
- member is under the care of an endocrinologist; and
- results of baseline liver function tests from within the past 30 days are provided; and
- one of the following:
- member has persistent or recurring disease following surgery and/or radiation; or
- member is not a candidate for surgery; and
- one of the following:
- inadequate response or adverse reaction to one somatostatin analog that does not require PA; or
- contraindication to somatostatin analogs; and
- one of the following:
- member has moderate-to-severe disease symptoms; or
- member has mild disease and one of the following:
- inadequate response or adverse reaction to one dopamine analog (e.g., cabergoline, bromocriptine) in combination with a somatostatin analog; or
- adverse reaction to one somatostatin analog that does not require PA; or
- contraindication to dopamine analogs.
Xermelo
- Documentation of the following is required:
- appropriate diagnosis; and
- inadequate response to one somatostatin analog therapy; and
- requested agent will be given in combination with somatostatin analog therapy; and
- requested quantity is ≤ 90 units/month.
Original Effective Date: 04/2003
Last Revised Date: 06/2018
Clinical Criteria Main Page | Back to top | Previous | Next
Last updated 07/15/19