Pharmacy Prior Authorization Criteria

Palsonify (paltusotine) - PA, NF

Indications for Prior Authorization

Palsonify (paltusotine)

• For diagnosis of Acromegaly
  Indicated for the treatment of adults with acromegaly who had an inadequate response to surgery and/or for whom surgery is not an option.

Criteria

Palsonify

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of acromegaly
AND
• One of the following:
• Patient has an inadequate response to surgery
OR
• Patient is not a candidate for surgery
AND
• Trial and failure, contraindication or intolerance to one of the following:
• generic octreotide
• generic lanreotide
AND
• Prescribed by or in consultation with an endocrinologist

Palsonify

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient demonstrates positive clinical response to therapy (e.g., clinically significant reduction in IGF-1/GH levels, reduction in Total Acromegaly Symptoms Diary (ASD) score)
AND
• Trial and failure, contraindication or intolerance to one of the following:
• generic octreotide
• generic lanreotide

Palsonify

Non Formulary

Length of Approval: 12 Month(s)

• Submission of medical records (e.g., chart notes) confirming diagnosis of acromegaly
AND
• Submission of medical records (e.g., chart notes) confirming one of the following:
• Patient has an inadequate response to surgery
OR
• Patient is not a candidate for surgery
AND
• Submission of medical records (e.g., chart notes) or paid claims confirming trial and failure, contraindication or intolerance to one of the following:
• generic octreotide
• generic lanreotide
AND
• Prescribed by or in consultation with an endocrinologist

P & T Revisions

2026-03-06, 2025-11-10

References

1. Palsonify Prescribing Information. Crinetics Pharmaceuticals, Inc. San Diego, CA. September 2025.

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Revision History

• 2026-03-06: Update to include embedded single step through octerotide or lanreotide. Addition of NF criteria.
• 2025-11-10: New Program

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