- Oncology: Carcinoid Syndrome:
Duration: 6 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: Yes
Concomitant Therapy Required with Somatostatin Analog Therapy: Yes
Patient Required to Try Increased Dosage of Sandostatin: No
Reauthorization Supporting Documentation Requirements: Chart Notes
- Prior Authorization: Oncology: Carcinoid Syndrome:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
- Quantity Limit: limit maximum 3 EA PER 1 day(s)
- Step Therapy: Oncology: Carcinoid Syndrome:
ST Single Generic
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