Octreotide Acetate Long-acting Products (Sandostatin LAR Depot, generic)

EviCore covers long‑acting octreotide for the FDA‑approved non‑oncology indication acromegaly and for compendial off‑label use in enterocutaneous and pancreatic fistulas, but excludes oncology indications. Coverage requires documentation of inadequate response to or ineligibility for surgery/radiotherapy (or tumor mass effects), a baseline IGF‑1 above lab ULN and endocrinologist involvement for acromegaly, documentation of the treatment context for fistulas (pancreatic fistulas limited to operative trauma/resection/acute or chronic pancreatitis or infection), adherence to dosing recommendations (acromegaly typically 20 mg IM q4 weeks; fistulas up to 40 mg IM q4 weeks) and specified approval durations (acromegaly 12 months, enterocutaneous 3 months, pancreatic 2 months) plus any applicable safety criteria.

"Acromegaly in individuals who have had an inadequate response to surgery and/or radiotherapy, or for whom surgery and/or radiotherapy, is not an option."