Octreotide acetate injection (Sandostatin LAR Depot, Sandostatin)

Covers Sandostatin LAR Depot and Sandostatin only for the FDA‑approved non‑oncology indication acromegaly (other uses excluded) when initial criteria are met: prescribed by or in consultation with an endocrinologist, a pretreatment IGF‑1 above the laboratory upper limit of normal, and one of inadequate response to or not a candidate for surgery/radiotherapy or tumor mass‑effect. Initial approval is for 3 months (renewals 12 months); if not currently on octreotide a ≥2‑week trial of short‑acting subcutaneous octreotide for tolerance is required before switching (recommended switch 20 mg IM q4w with dose adjustments to 10–40 mg based on response, 10 mg start for dialysis/cirrhosis), and continuation requires documented clinical/biochemical response (decrease/normalization of IGF‑1/GH or metabolic improvement).

"Treatment of acromegaly"

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