MYCAPSSA (octreotide) prior authorization criteria
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This document sets prior authorization (PA) requirements for MYCAPSSA (oral octreotide) for Mississippi Division of Medicaid members, including initial and re-authorization clinical criteria, dosing limits, and prescribing requirements.
No material clinical or coverage changes in this revision.
Coverage Criteria for MYCAPSSA (octreotide)
Initial Authorization
Covered when ALL of the following are met for Initial Authorization (6 months):
Initial authorization duration: 6 months
Re-Authorization
Covered when ALL of the following are met for Re-Authorization (1 year):
Re-authorization duration: 1 year
Use of MYCAPSSA is limited to maintenance therapy only and is not covered for patients who are newly diagnosed with acromegaly or who are naïve to somatostatin analog treatment. The policy requires that MYCAPSSA be prescribed for members who have already demonstrated response to and tolerance of injectable somatostatin analogs rather than as initial therapy.
Prior authorization for MYCAPSSA requires documented completion and tolerance of a six-month trial of either long-acting injectable somatostatin analog: octreotide LAR or lanreotide. Requests that lack documentation of this completed and tolerated six-month injectable trial will not meet the coverage criteria.
Dosing and Coding Limits
Provider Requirements and Prior Authorization Process
Prior authorization required for MYCAPSSA
Prior authorization is required for MYCAPSSA (octreotide). Approval will be considered only when the specified clinical and prescribing criteria are met; submit the Universal PA Form and supporting clinical documentation with the request.
- Prior authorization required for MYCAPSSA (octreotide).
- Approval considered when all clinical and prescribing criteria are met.
Six‑month trial of octreotide LAR or lanreotide required
Patient must have completed and tolerated a six-month trial of one long‑acting injectable somatostatin analog (octreotide LAR or lanreotide) prior to approval of oral MYCAPSSA for maintenance therapy.
- Completed and tolerated a six-month trial of octreotide LAR or lanreotide is required.
Submit Universal PA Form and supporting clinical documentation
Include the Universal PA Form plus supporting clinical documentation: diagnosis of acromegaly, laboratory IGF‑1 results with laboratory reference ranges, documentation of clinical symptoms and response, evidence of a completed and tolerated six‑month trial of octreotide LAR or lanreotide, and prescriber specialty or consultation note.
- Universal PA Form.
- Diagnosis of acromegaly and IGF‑1 results with reference ranges.
- Documentation of clinical symptoms and response and justification for inability to maintain injectable therapy.
- Evidence of completed, tolerated 6‑month trial of octreotide LAR or lanreotide.
- Prescriber specialty or endocrinology consultation note.
Triggers for denial and common reasons for coverage refusal
Requests may be denied if the criteria are not met. Common triggers for denial include patient age under 18, no documented elevated IGF‑1, absence of a completed and tolerated six‑month injectable somatostatin analog trial, prescribed dose exceeding 80 mg/day, or lack of endocrinologist prescribing/consultation.
- Patient is younger than 18 years.
- No documented elevated IGF‑1 above the laboratory upper limit of normal for age/sex.
- No documentation of a completed and tolerated 6‑month trial of octreotide LAR or lanreotide.
- Prescribed dose exceeds the 80 mg/day maximum.
- Medication not prescribed by or in consultation with an endocrinologist.
Definitions and Clinical Response
Background
MYCAPSSA (octreotide) is an oral somatostatin analog indicated for long-term maintenance treatment of acromegaly in patients who have already responded to and tolerated injectable somatostatin analogs. The policy requires biochemical confirmation of acromegaly (elevated IGF-1 using laboratory reference ranges) and clinical symptoms consistent with the disease, and it limits MYCAPSSA to maintenance use rather than initial therapy.
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