CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Somavert (pegvisomant) for acromegaly

Policy covers Somavert (pegvisomant) for the treatment of acromegaly when FDA-approved indications and specified prior authorization criteria are met, including documentation requirements for initial and continuation therapy. All other indications are considered experimental/investigational and not medically necessary.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySomavert (pegvisomant) for acromegaly

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required for initiation and continuation; submit required documentation including laboratory reports and chart notes to support diagnosis, pretreatment elevated IGF-1, prior surgery/radiotherapy response or clinical reason for no surgery/radiotherapy, and for continuation evidence of decreased or normalized IGF-1.

POLICY UPDATE CHANGES

No material changes to clinical coverage criteria or policy terms.

1Covered Indication (acromegaly)

All othersOther indications

12 moAuthorization duration

Coverage Summary

Policy covers Somavert (pegvisomant) for the treatment of acromegaly when FDA-approved indications and the specified prior authorization criteria are met, including documentation requirements for initial and continuation therapy. Authorization may be granted for up to 12 months. All other indications are considered experimental/investigational and not medically necessary.