- Prior Authorization: Documented Diagnosis: Yes
Duration: 12 Month(s)
- Neuroendocrine Tumor (NET):
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: = 12 month(s)
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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