Xermelo (telotristat ethyl)
Drugs for the Stomach : Drugs for Diarrhea
  • 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