UnitedHealthcare
Bynfezia Pen (octreotide acetate)
Hormones : Drugs for Growth
  • Prior Authorization: Acromegaly:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Duration: 12 Month(s)
    Reauthorization Required: Yes

    Neuroendocrine Tumor (NET), Oncology: Carcinoid Syndrome:
    Documented Diagnosis: Yes
    Duration: 12 Month(s)
    Reauthorization Required: Yes

  • Acromegaly:
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

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

    Oncology: Carcinoid Syndrome:
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    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
    Reauthorization Supporting Documentation Requirements: Chart Notes

  • Step Therapy: ST Single Generic

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