Subject: Specialty Quantity Limit Somavert 1711-H P2024

Drug

SOMAVERT  (pegvisomant)

Policy:

I.  PROGRAM DESCRIPTION

The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. The recommended dosing parameters for all FDA-approved indications fall within the standard limits. Coverage of an additional quantity may be reviewed on a case-by-case basis upon request.


II.  COVERED QUANTITIES

Medication	Standard Limit	FDA-recommended dosing
Somavert (pegvisomant) Inj 10 mg	30 per 30 days	Recommended starting dose: A loading dose of 40 mg (two 20 mg   subcutaneous injections), followed by 10 mg daily.     Dose adjustment:   •   Adjust dosage in 5 mg increments or decrements every 4-6       weeks until serum IGF-1 concentrations are maintained within       age-adjusted normal range.   •   Dosage range is 10 to 30 mg once daily
Somavert (pegvisomant) Inj 20 mg	30 per 30 days	Recommended starting dose: A loading dose of 40 mg (two 20 mg   subcutaneous injections), followed by 10 mg daily.     Dose adjustment:   •   Adjust dosage in 5 mg increments or decrements every 4-6       weeks until serum IGF-1 concentrations are maintained within       age-adjusted normal range.   •   Dosage range is 10 to 30 mg once daily
Somavert (pegvisomant) Inj 25 mg	30 per 30 days	Recommended starting dose: A loading dose of 40 mg (two 20 mg   subcutaneous injections), followed by 10 mg daily.     Dose adjustment:   •   Adjust dosage in 5 mg increments or decrements every 4-6       weeks until serum IGF-1 concentrations are maintained within       age-adjusted normal range.   •   Dosage range is 10 to 30 mg once daily
Somavert (pegvisomant) Inj 30 mg	30 per 30 days	Recommended starting dose: A loading dose of 40 mg (two 20 mg   subcutaneous injections), followed by 10 mg daily.     Dose adjustment:   •   Adjust dosage in 5 mg increments or decrements every 4-6       weeks until serum IGF-1 concentrations are maintained within       age-adjusted normal range.   •   Dosage range is 10 to 30 mg once daily

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Somavert [package insert]. New York, NY: Pharmacia & Upjohn Company LLC; July 2023.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

April 17, 2024