Pasireotide (Signifor®)

SELF ADMINISTRATION

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

Dosing:

  • 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

Approval:

Initial authorization: One year


 

Last review date: July 21, 2016

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