Octreotide Products (Sandostatin, Sandostatin LAR)

Covered: Sandostatin (octreotide) injection and Sandostatin LAR are covered only for FDA‑approved non‑oncology acromegaly (inadequate response to or not candidates for surgery/radiotherapy, or tumor mass effects); non‑approved/oncology uses are excluded. Key requirements: baseline IGF‑1 above the lab age/gender ULN, prescription by or in consultation with an endocrinologist, trial/initiation dosing (50 mcg SC TID x2 weeks then LAR 20 mg IM q4w for 3 months, or 20 mg q4w if transitioning), biochemical/clinical reassessment at ~3 months to adjust dose to 10/20/30/40 mg q4w as indicated (not >40 mg) and approvals limited to 12 months.

"FDA‑approved non-oncology indication: acromegaly."

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