Octreotide Products (Sandostatin, Sandostatin LAR)

Sandostatin and Sandostatin LAR (octreotide) are covered only for the FDA‑approved non‑oncology indication of acromegaly (oncology uses excluded). Coverage requires inadequate response to or ineligibility for surgery/radiotherapy (or tumor‑mass effects), a baseline IGF‑1 above the lab upper limit of normal, endocrinologist prescribing/consultation, the recommended lead‑in (50 mcg SC TID x2 weeks if not already on SC therapy) followed by LAR 20 mg every 4 weeks with a 3‑month GH/IGF‑1 and symptom reassessment to guide dose adjustments (10–40 mg q4w per criteria), approval for 12 months, and doses >40 mg q4w are not recommended.

"When requesting Sandostatin ® LAR Depot (octreotide acetate for injectable suspension) or Sandostatin ® (octreotide acetate injection) for non-oncology indication(s), the individual requiring treat..."

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