Mycapssa (octreotide) — United Healthcare
acromegaly
Preferred products
- Sandostatin (octreotide)
- Sandostatin LAR
- Somatuline Depot (lanreotide)
- bromocriptine mesylate
Initial criteria
- Diagnosis of acromegaly by ONE of the following: (1) Serum GH level > 1 ng/mL after a 2-hour oral glucose tolerance test (OGTT) at time of diagnosis OR (2) Elevated serum IGF-1 levels (above age- and gender-adjusted normal range) at time of diagnosis
- AND ONE of the following: (a) Inadequate response to surgical resection OR pituitary irradiation OR bromocriptine mesylate at maximally tolerated dose OR (b) Not a candidate for surgical resection OR pituitary irradiation OR bromocriptine mesylate at maximally tolerated dose
- AND Patient has responded to and tolerated treatment with ONE of the following somatostatin analogs: Sandostatin (octreotide) or Sandostatin LAR OR Somatuline Depot (lanreotide)
- AND Provider has submitted clinical justification why the patient is unable to be maintained on current octreotide or lanreotide therapy
- OR Patient is currently on Mycapssa therapy for acromegaly
Reauthorization criteria
- Documentation of positive clinical response to Mycapssa therapy
Approval duration
12 months