Mycapssa (octreotide) delayed-release capsules coverage
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Defines prior authorization recommendation, coverage criteria, and approval durations for Mycapssa (oral octreotide) for treatment of acromegaly in adults who have responded to and tolerated injectable somatostatin analogs, for Medical Mutual - Ohio pharmacy benefit.
No material clinical or coverage changes in this revision.
Coverage Criteria for Mycapssa (octreotide)
Recommended Authorization Criteria — Acromegaly
Coverage of Mycapssa is recommended when all of the following are met for acromegaly:
ALL of the following
ALL of the following
- Diagnosis of acromegaly (ICD-10 E22.0) when available for automation
ICD-10 code used for automation
ALL of the following
- Medication prescribed by or in consultation with an endocrinologist
ALL of the following
- Patient has previously responded to and tolerated treatment with octreotide or lanreotide
ALL of the following
- Baseline (prior to initiation of any somatostatin analog, dopamine agonist, or Somavert) IGF-1 level above the upper limit of normal for age and gender per lab reference
ALL of the following
- Patient is at least 18 years of age
Coding and Lookback Windows
| E22.0 | Acromegaly |
Prescriber, Prior Authorization, and Automation Rules
Prior authorization required; specialist prescriber for initial therapy
Prior authorization is recommended for pharmacy benefit coverage of Mycapssa. Initial approvals must be prescribed by or in consultation with a physician who specializes in the condition being treated (e.g., an endocrinologist); reauthorization requires documentation of response to therapy when reauthorization is allowed.
- Prior authorization recommended for Mycapssa pharmacy benefit coverage.
- Initial approval requires prescription by or in consultation with a specialist in the treated condition (endocrinologist).
- If reauthorization is allowed, a response to therapy is required for continuation unless otherwise noted.
Use automation when diagnosis, age, and prior-treatment lookback criteria are met
Automation may be used to approve requests when the specified diagnosis, age, and prior-treatment history are documented. For initial users automation requires documentation of ICD-10 E22.0, age ≥18, and a history of any octreotide, lanreotide, or other somatostatin analog within the previous 730 days. For continuing users automation requires ICD-10 E22.0, age ≥18, and history of Mycapssa use within the last 130 days.
- Initial user automation criteria: ICD-10 E22.0 (acromegaly), patient age 18 years or older, and history of any octreotide/lanreotide/other somatostatin analog within the prior 730 days.
- Continuing user automation criteria: ICD-10 E22.0, patient age 18 years or older, and history of Mycapssa use within the last 130 days.
Drug Definition
Initial Therapy — Approval Criteria and Duration
Initial Therapy
Initial approval criteria and duration:
ALL of the following
ALL of the following
- ICD-10 code E22.0 confirming diagnosis of acromegaly
- Patient is 18 years of age or older
- History of any octreotide product, lanreotide product, or other somatostatin analog within the previous 730 days
Lookback window: 730 days
ALL of the following
- Initial approval duration: 1 year
Continuation / Reauthorization Criteria
Continuation / Reauthorization
Criteria for continuing therapy and automation for continuing users:
ALL of the following
- ICD-10 code E22.0 confirming diagnosis of acromegaly
- Patient is 18 years of age or older
- History of Mycapssa use within the last 130 days may allow automation of approval for continuing users
Lookback window: 130 days
ALL of the following
- If reauthorization is allowed, documentation of response to therapy is required for continuation unless otherwise noted
ALL of the following
- Extended approval duration: 1 year
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