Lanreotide

This policy covers lanreotide (Somatuline Depot) for long‑term treatment of acromegaly in adults—administered as a deep subcutaneous injection (60, 90, or 120 mg every 4 weeks with dose titration based on GH and IGF‑1)—to reduce GH/IGF‑1 levels and control symptoms in patients inadequately controlled by or unsuitable for surgery/radiation. Coverage is limited to FDA‑approved or compendia‑supported uses (or off‑label uses supported by ≥2 peer‑reviewed articles), excludes oncologic indications, requires administration by a healthcare provider, and mandates specified GH/IGF‑1 thresholds and washout criteria for previously treated patients, with applicability determined by the member’s benefit plan.

"Coverage of any FDA‑approved drug when prescribed for a use recognized as safe and effective in one or more standard medical reference compendia adopted by the U."

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