Indications for Prior Authorization
- Adult Cushing’s disease
- Acromegaly (FDA approved Signifor LAR: 12/17/2014)
All of the following must be met as a condition for coverage
- Pituitary surgery is not an option or has not been curative
This Medication is Not Approvable for the following condition(s):
Any condition not listed above as an approved indication.
- Cushing's disease: Recommended dose: 0.3 to 0.9 mg twice a day.
- Acromegaly: Signifor LAR - Up to 40mg IM every 4 weeks for 3 months.
- Dosing titration: May increase to 60 mg IM every 28 days in patients who have not normalized growth hormone (GH) and/or insulin-like growth factor 1 (IGF-1) levels after 3 months.
Duration of Therapy
Initial authorization: one year
Western Health Advantage Pharmacy and Therapeutics Committee
Approved: May 2013
Last review date: July 21, 2016