3. Have baseline A1c or fasting glucose, thyroid-stimulating hormone (TSH), and electrocardiography (EKG) been checked?

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1 Pharmacy Prior Authorization AETA BETTER HEALTH PESLVAIA & AETA BETTER HEALTH KIDS Somatostatin Analogs (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to Aetna Better Health Pennsylvania / Aetna Better Health Kids at When conditions are met, we will authorize the coverage of Somatostatin Analogs (Medicaid). Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Drug ame (circle drug) Sandostatin LAR Depot Signifor Signifor LAR Somatuline Depot Other, specify drug Quantity Frequency Strength Route of administration Expected length of therapy Patient information Patient name: Patient ID: Patient Group o.: Patient DOB: Patient phone: Prescribing physician Physician name: Specialty: PI number: Physician fax: Physician phone: Physician address: City, state, zip: Diagnosis: ICD Code: Circle the appropriate answer for each question. 1. Has this plan authorized this medication in the past for this member (i.e., previous authorization is on file under this plan)? [If yes, skip to question 28.] 2. Is the request for Sandostatin LAR? [If no, skip to question 5.] 3. Have baseline A1c or fasting glucose, thyroid-stimulating hormone (TSH), and electrocardiography (EKG) been checked? Reference umber: C14476-A/ Effective Date: 12/03/2018 1

2 4. Has the member had a positive response to octreotide immediate release injection for at least 2 weeks? [If yes, skip to question 16.] 5. Is the request for Signifor (but OT Signifor LAR)? [If no, skip to question 10.] 6. Have baseline A1c, fasting plasma glucose, electrocardiography (EKG), potassium, magnesium, thyroid-stimulating hormone (TSH), and liver function tests (LFTs) been checked? 7. Does the member have a diagnosis of Cushing s Syndrome? 8. Does the member have persistent disease after pituitary surgery, or is surgery not an option for this member? 9. Has the member had a trial and failure of cabergoline or does the member have an intolerance or contraindication to cabergoline? If yes, indicate which apply: 10.Is the request for Signifor LAR? [If no, skip to question 13.] 11.Has the member had a trial and failure of Sandostatin LAR, or an intolerance Reference umber: C14476-A/ Effective Date: 12/03/2018 2

3 to octreotide or Sandostatin LAR? 12.Have baseline A1c, fasting plasma glucose, electrocardiography (EKG), potassium, magnesium, thyroid-stimulating hormone (TSH), and liver function tests (LFTs) been checked? [If yes, skip to question 20.] 13.Is the request for Somatuline Depot? 14.Does the member meet A of the following criteria: A) member had a trial and failure of Sandostatin LAR, B) member had an intolerance to octreotide or Sandostatin LAR, or C) member has a diagnosis of Gastroenteropancreatic euroendocrine Tumors (GEP-ET)? 15.Has a baseline A1c or fasting glucose been checked? 16.Does the member have a diagnosis of carcinoid tumor or VIPomas? [If yes, skip to question 19.] 17.Does the member have a diagnosis of gastroenteropancreatic neuroendocrine tumor (GEP-ET)? [If no, skip to question 20.] 18.Did the member have persistent disease after surgical resection, or is the member not a candidate for surgery? 19.Is the requested drug prescribed by or in consultation with an oncologist or endocrinologist? Reference umber: C14476-A/ Effective Date: 12/03/2018 3

4 20.Does the member have a diagnosis of acromegaly? 21.Is the requested drug prescribed by or in consultation with an endocrinologist? 22.Does the member have persistent disease following pituitary surgery? [If yes, skip to question 24.] 23.Is surgical resection not an option for this member due to A of the following: A) majority of tumor cannot be resected, B) member is a poor surgical candidate based on comorbidities, or C) member prefers medical treatment over surgery, or refuses surgery? 24.Does the member have a baseline insulin-like growth factor 1 (IGF-1) level greater than or equal to 2 times the upper limit of normal (UL) for age? 25.Does the member have a history of persistently elevated insulin-like growth factor 1 (IGF-1) levels while on maximally tolerated doses of cabergoline for at least 6 months? 26.Was the member unable to tolerate a trial of cabergoline or does the member have a contraindication to cabergoline? If yes, indicate which apply: 27.Is the member at least 18 years of age? [o further questions.] 28.Has the member had a clinical response and/or symptom improvement since starting the requested medication? Reference umber: C14476-A/ Effective Date: 12/03/2018 4

5 29.Is the member s A1c and/or fasting glucose level controlled? If no, submit documentation describing treatment plan to improve blood glucose: 30.Is this a renewal for Signifor for treatment of Cushing s syndrome? [If no, skip to question 33.] 31.Has the member s cortisol level decreased or normalized since starting Signifor? Please submit labs or document result and test date: 32.Have liver function tests (LFT s) been checked since starting Signifor? [o further questions.] 33.Does the member have a diagnosis of acromegaly? [If no, skip to question 35.] 34.Has the member s IGF-1 level decreased or normalized since starting the requested medication? Please submit labs or document result and test date: [o further questions.] 35.Does the member have a diagnosis of carcinoid tumor or VIPomas? Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature Prescriber (Or Authorized) Signature Date Date Reference umber: C14476-A/ Effective Date: 12/03/2018 5

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