| Anthem Blue Cross (HMO, PPO, EPO) |
| Bynfezia Pen (octreotide acetate) |
| Hormones : Drugs for Growth |
- Step Therapy Applies
- Available only through Specialty Pharmacy;
- Acromegaly, Neuroendocrine Tumor (NET):
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Oncology: Carcinoid Syndrome:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Requires diagnosis of Carcinoid syndrome with diarrhea: Yes
Concomitant Therapy Required with Somatostatin Analog Therapy: No
Patient Required to Try Increased Dosage of Sandostatin: No
- Prior Authorization: Documented Diagnosis: Yes
Duration: 1 year(s)
- Quantity Limit: 1 pen per 14 day(s).
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