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Coverage criteria policies

Somatostatin Analogues for Acromegaly (Sandostatin LAR®, Somatuline Depot®, Signifor LAR®, Somavert®)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative Process

Somatuline Depot®, Signifor LAR®, and Somavert® require prior authorization for use in Acromegaly from Pharmacy Administration. Prior authorization is not required for oncology uses.

Sandostatin LAR® does not require prior authorization.

Coverage

Sandostatin LAR® does not require prior authorization.

Somatuline Depot®, Signifor LAR®, and Somavert® are generally covered when used for the treatment of (1) patients with acromegaly for whom surgery is not an option or has not been curative and (2) who have failed one somatostatin analogue.

Initial approvals are for six months. Approvals will be provided annually thereafter for responders with demonstrated effect.

Definitions

Sandostatin LAR Depot (octreotide acetate for injectable suspension) is a somatostatin analogue indicated for Treatment in patients who have responded to and tolerated subcutaneous immediate-release Sandostatin Injection for:

  • Long-term maintenance therapy in acromegalic patients who have had inadequate response to surgery and/or radiotherapy or for whom surgery and/or radiotherapy is not an option (the goal of treatment in acromegaly is to reduce GH and IGF-1 levels to normal)
  • Long-term treatment of the severe diarrhea and flushing episodes associated with metastatic carcinoid tumors
  • Long-term treatment of the profuse watery diarrhea associated with VIP-secreting tumors.

In patients with carcinoid syndrome and VIPomas, the effect of Sandostatin Injection and Sandostatin LAR Depot on tumor size, rate of growth and development of metastases has not been determined.

Somatuline Depot (lanreotide) Injection is a somatostatin analog indicated for:

  • Long-term maintenance therapy in acromegalic patients who have had inadequate response to or cannot be treated with surgery and/or radiotherapy
  • Treatment of patients with unresectable, well-or moderately-differentiated, locally advanced or metastatic gastroenteropancreatic neuroendocrine tumors (GEP-NETs) to improve progression-free survival.

Signifor LAR is a somatostatin analog indicated for the treatment of patients with acromegaly who have had an inadequate response to surgery and/or for whom surgery is not an option.

Somavert (pegvisomant for injection) is a growth hormone receptor antagonist indicated for the treatment of acromegaly in patients who have had an inadequate response to surgery or radiation therapy, or for whom these therapies are not appropriate. The goal of treatment is to normalize serum insulin-like growth factor-I (IGF-1) levels.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

HCPCS

Code

Description

J2502

Injection, pasireotide long acting, 1 mg

J2353

Injection, octreotide, depot form for intramuscular injection, 1 mg

J1930

Injection, lanreotide, 1 mg

J3490

Unclassified drugs (Somavert)

C9399

Unclassified drugs or biological (Somavert)

NDC

Codes

Description

00078081181

Sandostatin LAR Depot 10 mg kit

00078081881

Sandostatin LAR Depot 20 mg kit

00078082581

Sandostatin LAR Depot 30 mg kit

15054112003

Somatuline Depot 120mg/0.5mL solution

15054106003

Somatuline Depot 60mg/0.2mL solution

15054109003

Somatuline Depot 90mg/0.3mL solution

00078064161

Signifor LAR 20mg suspension

00078064181

Signifor LAR 20mg suspension

00078064261

Signifor LAR 40mg suspension

00078064281

Signifor LAR 40mg suspension

00078064361

Signifor LAR 60mg suspension

00078064381

Signifor LAR 60mg suspension

00009517502

Somavert 10 mg solution

00009517602

Somavert 10 mg solution

00009716601

Somavert 10mg solution

00009517802

Somavert 15 mg solution

00009716801

Somavert 15mg solution

00009518002

Somavert 20 mg solution

00009718801

Somavert 20mg solution

00009519901

Somavert 25 mg solution

00009520104

Somavert 25 mg solution

00009719901

Somavert 25mg solution

00009520001

Somavert 30 mg solution

00009537604

Somavert 30 mg solution

00009720001

Somavert 30mg solution

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Sandostatin LAR Depot [Prescribing Information]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; July 2016.
  2. Somatuline Depot [Prescribing Information]. Basking Ridge, NJ: Ipsen Biopharmaceuticals, Inc; December 2014.
  3. Signifor LAR [Prescribing Information]. East Hanover, NJ: Novartis Pharmaceuticals Corporation December 2014.
  4. Somavert [Prescribing Information]. New York, NY: Pfizer, Inc; April 2016.
  5. Acromegaly: An Endocrine Society Clinical Practice Guideline. Laurence Katznelson, Edward R. Laws, Jr, Shlomo Melmed, Mark E. Molitch, Mohammad Hassan Murad, Andrea Utz, and John A. H. Wass http://press.endocrine.org/doi/pdf/10.1210/jc.2014-2700
  6. Schmid HA1, Brueggen J. Effects of somatostatin analogs on glucose homeostasis in rats. Accessed online February 24, 2015 at: http://joe.endocrinology-journals.org/content/212/1/49.long
  7. National Endocrine and Metabolic Diseases Information Service (NEMDIS). A service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH). “Acromegaly Page.” Accessed online February 24, 2015 at: http://www.endocrine.niddk.nih.gov/pubs/acro/acro.aspx#what

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Policy activity

  • 08/17/2015 - Date of origin
  • 01/01/2016 - Effective date
Review date
  • 08/2017

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