- Step Therapy: Acromegaly:
ST Single Generic
- Prior Authorization: Acromegaly:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 12 Month(s)
Neuroendocrine Tumor (NET), Oncology: Carcinoid Syndrome: Documented Diagnosis: Yes
Duration: 12 Month(s)
- Acromegaly:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Neuroendocrine Tumor (NET): Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Oncology: Carcinoid Syndrome: Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Requires diagnosis of Carcinoid syndrome with diarrhea: No
Concomitant Therapy Required with Somatostatin Analog Therapy: No
Patient Required to Try Increased Dosage of Sandostatin: No
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