CurrentColorado Rocky Mountain Health PlansPolicy 2026 P 1340-6

Mycapssa® (octreotide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Defines prior authorization and reauthorization clinical criteria for Mycapssa (oral octreotide) for UnitedHealthcare commercial plans, including initial eligibility (acromegaly and prior response/tolerability to injectable somatostatin analog) and reauthorization requirement (positive clinical response).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyMycapssa® (octreotide) - Prior Authorization/Notification - UnitedHealthcare Commercial Plans

Policy CodePolicy 2026 P 1340-6

Change TypeClarified; Revised

Effective DateApr 1, 2026

Next Review Date

Key ActionObtain prior authorization with documentation of acromegaly diagnosis and prior response/tolerability to octreotide or lanreotide for initial approval; document positive clinical response for reauthorization.

SourceLink

POLICY UPDATE CHANGES

Added Lanreotide Injection as an example of lanreotide and noted injectable somatostatin analogs may be subject to additional benefit and coverage review requirements.

Annual review performed in 1/2026 with updates to examples and exclusion footnote.

12 monthsAuthorization duration

1Required prior therapy (class)

Coverage Summary

Defines prior authorization and reauthorization clinical criteria for Mycapssa (oral octreotide) for UnitedHealthcare commercial plans: initial authorization requires diagnosis of acromegaly and prior response and tolerability to an injectable somatostatin analog (e.g., octreotide or lanreotide); reauthorization requires documentation of a positive clinical response. Authorization duration is 12 months.

Initial Therapy Criteria

Initial Authorization

Mycapssa will be approved based on both of the following criteria:

ALL of the following

Diagnosis of acromegaly
ONE of
- Octreotide (e.g., Sandostatin, Sandostatin LAR)
  Coverage of Sandostatin and Sandostatin LAR may be subject to additional benefit and coverage review requirements
- Lanreotide (e.g., Lanreotide Injection, Somatuline Depot)
  Coverage of Lanreotide Injection and Somatuline Depot may be subject to additional benefit and coverage review requirements

ref": "b1_0

title": "Initial Authorization

Documentation Required

Documentation of prior therapy and response

For initial authorization, document prior treatment with octreotide or lanreotide and that the patient responded to and tolerated that therapy. This documentation is required to support initial approval.

Initial approvals require prior authorization
Authorization will be issued for 12 months

Continuation / Reauthorization Criteria

Reauthorization

Mycapssa will be approved for reauthorization when the following is met:

Documentation of positive clinical response to Mycapssa therapy

Positive clinical response: Not specifically defined in policy; requires documentation by provider to support reauthorization.

Prior Authorization

Prior authorization required

Prior authorization is required for both initial and reauthorization requests. Authorization will be issued for 12 months.

Authorization will be issued for 12 months
Approvals may be based on previous claim/medication history and diagnosis codes

Unproven / Exclusions

Policy notes that injectable somatostatin analogs may be subject to additional benefit and coverage review requirements and that Mycapssa may be excluded from some plan coverage. The change control history and updates in 1/2026 added Lanreotide Injection as an example and included an exclusion footnote stating Mycapssa is typically excluded and plan-specific exclusions may apply.

Applicable Codes

ICD-10 diagnosis used to support approvalsICD-10

Acromegaly (specific ICD-10 codes not listed in policy)

Examples of prior therapies (informational)mixed

drug-class	Octreotide (e.g., Sandostatin, Sandostatin LAR) - example prior injectable somatostatin analog
drug-class	Lanreotide (e.g., Lanreotide Injection, Somatuline Depot) - example prior injectable somatostatin analog

Provider Actions & Operational Rules

Billing Rule

Supply limits and medical necessity may apply

UnitedHealthcare may apply supply limits and medical necessity reviews when processing Mycapssa requests. Approval decisions may also use automated or claims-based processes.

Approvals may be based on previous claim/medication history, diagnosis codes and claim logic
Supply limits and medical necessity reviews may be in place

Documentation Required

Documentation required for reauthorization

For reauthorization, the provider must document a positive clinical response to Mycapssa therapy to support continued approval.

Positive clinical response is not specifically defined in the policy and requires provider documentation

Background

Mycapssa is an oral somatostatin analog indicated for long-term maintenance treatment of acromegaly in patients who have responded to and tolerated octreotide or lanreotide. The policy reiterates that injectable somatostatin analogs (examples: Sandostatin, Sandostatin LAR, Lanreotide Injection, Somatuline Depot) may be subject to separate benefit and coverage review requirements.

Revision History

1/2026annual_reviewLatest