- Prior Authorization: Documented Diagnosis: Yes
Duration: 1 year(s)
- Quantity Limit: limit maximum 900 ML PER 11 day(s)
- Acromegaly:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Endocrinologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Neuroendocrine Tumor (NET):
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Oncology: Carcinoid Syndrome:
Age Requirement: >= 18
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Oncologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
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
- Available through Specialty Pharmacy;
- Peanut Allergy:
Age Requirement: >= 4
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
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