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Patient Authorization Form

Patient Representative Amendment to the Patient Authorization

The Pfizer Bridge Program™ can help your patients
access SOMAVERT

Pfizer Bridge Program fax number: 800-479-2562

Pfizer Bridge Program Hotline: 800-645-1280

Helping patients access SOMAVERT^® (pegvisomant for injection)

Step 1: Fax the completed Statement of Medical Necessity (SMN) to the Pfizer Bridge Program. Click here to get an SMN.

Step 2: A Patient Care Consultant (PCC) is assigned to your patient and begins the insurance verification and reimbursement process.

Step 3: The PCC assesses the benefits options for the patient.

Step 4: If patient's insurance covers treatment with SOMAVERT, a starter kit will be shipped to the patient.

Patient support that can help improve access to treatment and reimbursement

On receipt of the SMN, your patient is assigned to a PCC – a registered nurse who helps with
- Medical insurance investigation and verification
- Insurance paperwork
- Appeals coordination
- Alternate coverage research
The Pfizer Bridge Program Hotline (800-645-1280) offers assistance to patients and physicians regarding
- Product information about SOMAVERT
- Shipping information
- Insurance reimbursement status
- Product administration (available 24 hours a day)
Patients enrolled in the Pfizer Bridge Program have access to SOMAVERT through a mail-order pharmacy for reliable, convenient delivery.

Important Information for Healthcare Professionals:

SOMAVERT is indicated for the treatment of acromegaly in patients who have had an inadequate response to surgery and/or radiation therapy and/or other medical therapies, or for whom these therapies are not appropriate. The goal of treatment is to normalize serum IGF-I levels.

ALT, AST, TBIL, and ALP levels should be obtained prior to initiating therapy with SOMAVERT. If levels are normal, monitor at monthly intervals for the first 6 months of treatment, quarterly for the next 6 months, and then biannually for the next year. If patients exhibit symptoms suggestive of hepatitis or other liver injury, SOMAVERT should be discontinued and a comprehensive hepatic workup should be performed immediately. Please consult the full prescribing information for complete liver monitoring schedules.

SOMAVERT is contraindicated in patients with a history of hypersensitivity to any of its components. The stopper on the vial of SOMAVERT contains latex.

After initiation of therapy with SOMAVERT, glucose tolerance may increase in some patients. These patients should be carefully monitored and doses of antidiabetic medicines reduced as necessary.

Patients should be carefully observed for the clinical signs and symptoms of a GH-deficient state, and serum IGF-I level concentrations should be monitored and maintained within the age-adjusted normal range (by adjustment of the dose of SOMAVERT).

All patients with GH-secreting tumors, including those receiving SOMAVERT, should be carefully monitored for changes in tumor volume.

Patients on opioids often needed higher serum pegvisomant concentrations to achieve appropriate IGF-I level suppression compared with patients not receiving opioids.

The most common adverse events (>10% and at frequencies greater than placebo) in 1 of the 3 active treatment arms in a placebo-controlled study (n = 112) include infection, pain, diarrhea, nausea, flu syndrome, abnormal liver function tests, and injection-site reaction.

For full prescribing information, click here.

The health information contained herein is provided for educational purposes only and is not intended to replace discussions with a healthcare provider. All decisions regarding patient care must be made with a healthcare provider, considering the unique characteristics of the patient.

The product information provided in this site is intended only for residents of the United States. The products discussed herein may have different product labeling in different countries.

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