CurrentNeighborhood Health Plan of Rhode IslandPolicy 2097-A
Somavert (pegvisomant) for acromegaly
Policy governs prior authorization coverage criteria for Somavert (pegvisomant) for treatment of acromegaly, including required documentation for initial and continuation approvals and statement that non‑FDA indications are investigational.
Policy Summary
PayerNeighborhood Health Plan of Rhode Island
PolicySomavert (pegvisomant) for acromegaly
Policy CodePolicy 2097-A
Change TypeNo material changes
Effective Date
Next Review Date
Key ActionObtain prior authorization with required documentation: initial requests must include a pretreatment IGF-1 lab report and chart notes documenting inadequate/partial response to or ineligibility for surgery or radiotherapy; continuation requests must include current IGF-1 labs or chart notes showing improvement.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes
1Covered Indications (acromegaly)
All othersNon‑covered indications
Coverage Summary
This policy governs prior authorization coverage criteria for Somavert (pegvisomant) for the treatment of acromegaly. Coverage is restricted to the FDA‑approved indication (acromegaly in patients with inadequate response to or inappropriate candidates for surgery or radiotherapy) and is covered with criteria. Authorization (initial and continuation) requires submission of specified laboratory and chart documentation to support use.