CurrentCignaPolicy N/A

Somatostatin Analogs - Mycapssa Prior Authorization Policy

Defines Cigna's prior authorization requirements and coverage criteria for Mycapssa (oral octreotide) for maintenance treatment of acromegaly in members of Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicySomatostatin Analogs - Mycapssa Prior Authorization Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document pretreatment IGF-1 > laboratory upper limit of normal and prescriber attestation of response to an injectable somatostatin analog.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yearapproval duration for FDA‑approved indication

AcromegalyFDA‑approved indication covered

Endocrinologistprescriber requirement

Baseline IGF-1pretreatment IGF-1 requirement

Coverage Criteria for Mycapssa (octreotide)

inv-01: FDA‑Approved Indication (Acromegaly) - Initial/Continuation

Covered when ALL of the following are met:

Initial therapy: Diagnosis of acromegaly and pretreatment (baseline) IGF-1 level above the upper limit of normal for age and gender for the reporting laboratory.Pretreatment (baseline) IGF-1 > upper limit of normal

Prior response requirement: Prescriber attestation that the patient has responded to one octreotide acetate injection product or Somatuline Depot (lanreotide injection).

Prescriber specialty: Medication is prescribed by or in consultation with an endocrinologist.

Because of the specialized skills required for evaluation and monitoring, prescription by or consultation with a physician who specializes in the condition is required.

Policy Summary

PayerCigna

PolicySomatostatin Analogs - Mycapssa Prior Authorization Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document pretreatment IGF-1 > laboratory upper limit of normal and prescriber attestation of response to an injectable somatostatin analog.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Affected Codes and Clinical Data Elements

Affected prescription/benefit codesmixed

affected codes

The document references that prior authorization affects prescription benefit billing codes; specific CPT/HCPCS/NDC codes are not listed in the policy text.

inv-05: Pretreatment IGF-1

Pretreatment IGF-1 requirementBaseline IGF-1 must be above the laboratory upper limit of normal for the patient’s age and gender

Laboratory-specific reference rangesReference ranges for IGF-1 vary among laboratories; use the reporting laboratory's age- and gender-specific upper limit of normal

Timing relative to therapyIGF-1 must be the level measured prior to initiation of any somatostatin analog therapy

Applies to somatostatin analogsRequirement applies when considering initiation of Mycapssa (oral octreotide) or other somatostatin analogs

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization Required — Prior authorization is recommended for prescription benefit coverage of Mycapssa. All approvals are provided for a 1‑year duration when criteria are met. Because of the specialized skills required for evaluation, diagnosis, and monitoring of patients treated with Mycapssa, approval requires the drug to be prescribed by or in consultation with a physician who specializes in the condition being treated.

Approvals valid for 1 year when criteria are met
Prescriber must be a specialist or consult with a specialist (endocrinologist)

Prior Authorization

Prior Response to Injectable Somatostatin Analog

Response to Injectable Somatostatin Analog Required — For FDA‑approved acromegaly maintenance use, the patient must have demonstrated a prior clinical response to an octreotide acetate injection product or to Somatuline Depot (lanreotide injection) as attested by the prescriber.

Requirement: documented prior response to one octreotide acetate injection product or lanreotide (Somatuline Depot)
This prior response must be stated by the prescriber in the authorization request

Documentation Required

Required Clinical & Administrative Documentation

Required Clinical and Administrative Documentation — Submit documentation supporting the medical necessity of Mycapssa, including pretreatment (baseline) IGF‑1 level above the laboratory upper limit of normal for age and sex, prescriber attestation of prior response to an injectable somatostatin analog (octreotide acetate injection or lanreotide), and evidence the medication is prescribed by or in consultation with an endocrinologist. Coverage determinations are made in consideration of the applicable benefit plan terms and controlling laws/regulations; providers must submit requests using the correct prior‑authorization forms and processes applicable to the member's plan.

Pretreatment (baseline) IGF‑1 level reported and compared to lab reference range
Prescriber attestation of prior response to one octreotide acetate injection product or Somatuline Depot (lanreotide)
Documentation that prescriber is an endocrinologist or that endocrinology consultation occurred
Use the member's applicable prior‑authorization forms/process and include relevant benefit plan information

Denial Risk

Not Medically Necessary: Other Uses

Not Medically Necessary Uses — Mycapssa is considered not medically necessary for any indications other than FDA‑approved acromegaly maintenance after documented response to an injectable somatostatin analog. Requests for other indications should be denied unless new peer‑reviewed evidence supports coverage and the applicable benefit plan permits.

Denial for uses other than FDA‑approved acromegaly maintenance after prior response to an injectable somatostatin analog

OpenPayer

Somatostatin Analogs - Mycapssa Prior Authorization Policy

Coverage Criteria for Mycapssa (octreotide)

Affected Codes and Clinical Data Elements

Provider Requirements and Prior Authorization

Background

Definitions