CurrentCareSource Georgia MedicaidPolicy GA-MED-P-366579

Mycapssa (octreotide) for acromegaly

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This policy governs pharmacy prior authorization and coverage of Mycapssa (octreotide) for CareSource Georgia Medicaid members with acromegaly. It establishes initial authorization, reauthorization, prescribing, dosing, quantity, and documentation requirements.

Policy Summary

PayerCareSource Georgia Medicaid

PolicyMycapssa (octreotide) for acromegaly

Policy CodePolicy GA-MED-P-366579

Change TypeMaterial update

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionSubmit documentation that the member has responded to at least 3 months of injectable octreotide or lanreotide before requesting oral Mycapssa authorization.

SourceLink

POLICY UPDATE CHANGES

The policy clarified Mycapssa dosing, including titration in 20 mg increments, a maximum dose of 80 mg per day, and a quantity limit of 112 capsules per 28 days.

The policy removed the requirement to document prior surgery or that surgery was not an option.

The policy updated its references.

18+ yearsMinimum age

3 monthsPrior injectable therapy

6 monthsInitial authorization

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CurrentCareSource Georgia MedicaidPolicy GA-MED-P-366579

Mycapssa (octreotide) for acromegaly

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Sign up for caresourcegeorgia Policy GA-MED-P-366579 alerts

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Policy Summary

PayerCareSource Georgia Medicaid

PolicyMycapssa (octreotide) for acromegaly

Policy CodePolicy GA-MED-P-366579

Change TypeMaterial update

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionSubmit documentation that the member has responded to at least 3 months of injectable octreotide or lanreotide before requesting oral Mycapssa authorization.

SourceLink

POLICY UPDATE CHANGES

The policy clarified Mycapssa dosing, including titration in 20 mg increments, a maximum dose of 80 mg per day, and a quantity limit of 112 capsules per 28 days.

The policy removed the requirement to document prior surgery or that surgery was not an option.

The policy updated its references.

18+ yearsMinimum age

3 monthsPrior injectable therapy

6 monthsInitial authorization

80 mg/dayMaximum dose

112 capsules/28 daysQuantity limit

Coverage Criteria

Initial Therapy

Covered when ALL of the following requirements are met:

ALL of the following

Member is 18 years old or older.
Medication is prescribed by or in consultation with an endocrinologist.
Member has a documented diagnosis of acromegaly.
Member has been stabilized on injectable octreotide or lanreotide for at least 3 months, with documentation of IGF-1 demonstrating response to treatment.
Member has documented rationale for why it is medically necessary to switch to the oral formulation of octreotide, such as injection site reactions or ongoing symptoms despite biochemical control.
Initial dose is 40 mg orally per day, given as 20 mg orally twice daily; dose may be titrated in 20 mg increments based on IGF-1 levels, up to a maximum of 80 mg orally per day, given as 40 mg orally twice daily.
Quantity limit: 112 capsules per 28 days.

Continuation Therapy

Covered for reauthorization when the following requirement is met:

ALL of the following

Chart notes or a laboratory report show maintained or normalized IGF-1.

CareSource considers Mycapssa (octreotide) not medically necessary for the treatment of conditions that are not listed in this document. For any other indication, please refer to the Off-Label policy.

Mycapssa is not medically necessary for conditions or indications that are not listed in this policy.

Authorization and Documentation Requirements

Prior Authorization

Initial Pharmacy Prior Authorization Required

Pharmacy prior authorization is required for Mycapssa (oral octreotide) for long-term maintenance treatment of acromegaly. When all initial authorization requirements are met, coverage is approved for 6 months.

Member must be at least 18 years old.
Mycapssa must be prescribed by or in consultation with an endocrinologist.
The member must have a documented diagnosis of acromegaly.
The member must have demonstrated response to prior injectable octreotide or lanreotide therapy.
The requested oral formulation must be medically necessary.
Initial dose: 40 mg orally daily, given as 20 mg twice daily; titrate in 20 mg increments based on IGF-1 levels.
Maximum dose: 80 mg orally daily, given as 40 mg twice daily.
Quantity limit: 112 capsules per 28 days.

Medication Background

Mycapssa is a delayed-release oral capsule formulation of octreotide and a somatostatin analog indicated for long-term maintenance treatment of acromegaly in patients who have responded to and tolerated octreotide or lanreotide. Acromegaly is typically caused by a growth-hormone-secreting pituitary adenoma.

Initial Mycapssa Authorization

For initial authorization, all of the following medical-necessity requirements must be met.

Initial Mycapssa authorization

Clinical eligibility
- The member is 18 years old or older and has a documented diagnosis of acromegaly.Age >= 18 years
- The medication is prescribed by or in consultation with an endocrinologist.
Prior treatment response
- The member has been stabilized on injectable octreotide or lanreotide for at least 3 months, with documentation of IGF-1 demonstrating response to treatment.

Mycapssa Reauthorization

For reauthorization, the following treatment-response requirement must be met.

Continuation requirement: Chart notes or a laboratory report must show maintained or normalized IGF-1.Maintained or normalized IGF-1

When the requirement is met, approval is for an additional 12 months.

Required Prior Therapy

Step	Prior therapy required	Minimum duration	Treatment response
1	Injectable octreotide or lanreotide; member must be stabilized before switching to oral Mycapssa	At least 3 months	IGF-1 must demonstrate response to treatment

Dosing and Quantity Parameters

Quantity Limits

MedicationMycapssa (octreotide)

Quantity limit112 capsules per 28 days

Initial dose40 mg orally per day, given as 20 mg orally twice daily

Maximum dose80 mg orally per day, given as 40 mg orally twice daily

Policy Summary

PayerCareSource Georgia Medicaid

PolicyMycapssa (octreotide) for acromegaly

Policy CodePolicy GA-MED-P-366579

Change TypeMaterial update

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionSubmit documentation that the member has responded to at least 3 months of injectable octreotide or lanreotide before requesting oral Mycapssa authorization.

SourceLink

On This Page

Documentation Required

Reauthorization Requires IGF-1 Evidence

For reauthorization, submit evidence that the member’s IGF-1 has remained maintained or has normalized. When this requirement is met, an additional 12 months of coverage may be approved.

Reauthorization period: additional 12 months.
Acceptable evidence includes chart notes or a laboratory report documenting maintained or normalized IGF-1.

Unsupported block type: step_therapy

Unsupported block type: documentation

Documentation Required

Oral Formulation Medical Necessity

Document why switching from injectable therapy to oral octreotide is medically necessary. Examples include injection-site reactions or ongoing symptoms despite biochemical control.

Include the clinical rationale for the switch in the medical record or authorization request.
The rationale should explain why continued injectable therapy is not appropriate or why the oral formulation is needed.

Unsupported block type: documentation

Denial Risk

Initial Criteria Not Met

Initial authorization may be denied when any required eligibility, prescribing, diagnostic, prior-treatment, response, oral-formulation, dosing, or quantity-limit condition is not met or adequately documented.

Member is younger than 18 years.
Medication is not prescribed by or in consultation with an endocrinologist.
Acromegaly is not documented.
The member has not been stabilized on injectable octreotide or lanreotide for at least 3 months.
IGF-1 documentation does not demonstrate response to prior treatment.
Medical necessity for switching to oral octreotide is not documented.
The requested dose exceeds the policy limits or the quantity exceeds 112 capsules per 28 days.

Denial Risk

Insufficient Reauthorization Evidence

Reauthorization may be denied when the submitted documentation does not show that IGF-1 has been maintained or normalized.

Chart notes or a laboratory report must support the IGF-1 result.
A request without sufficient evidence of maintained or normalized IGF-1 does not meet the reauthorization requirement.

Denial Risk

Unlisted Indication Not Covered

Mycapssa is not medically necessary for conditions or indications that are not listed in this policy. For any other indication, refer to the Off-Label policy.

Coverage is limited to the policy’s listed acromegaly indication.
Unlisted indications are not medically necessary under this policy.
Refer to the Off-Label policy for other indications.

Medical necessity for oral formulation

The member has documented rationale for why it is medically necessary to switch to the oral formulation of octreotide, such as injection-site reactions or ongoing symptoms despite biochemical control.

Dosing and quantity limits

The initial dose is 40 mg orally per day, given as 20 mg orally twice daily. The dose may be titrated in 20 mg increments based on IGF-1 levels. The maximum dose is 80 mg orally per day, given as 40 mg orally twice daily, and the quantity limit is 112 capsules per 28 days.Initial 40 mg/day; titrate in 20 mg increments; maximum 80 mg/day; 112 capsules/28 days