UnitedHealthcare Sandostatin Prior Auth Update

Coverage Criteria for Subcutaneous Octreotide (Sandostatin)

Patients less than 19 years of age - Initial Authorization

Covered when ALL of the following are met

Pediatric oncology: (1) Patient is less than 19 years of age AND (2) Treatment is for an oncology indication

Authorization will be issued for 12 months

Acromegaly

Covered when ALL of the following are met

Acromegaly initial: (1) Diagnosis of acromegaly AND (2) either (a) inadequate response to surgical resection, pituitary irradiation, or dopamine agonist therapy OR (b) not a candidate for those interventions

Authorization will be issued for 12 months

Acromegaly reauthorization: Documentation of positive clinical response to Sandostatin therapy

Authorization will be issued for 12 months

Meningioma

Covered when ALL of the following are met

Meningioma initial: (1) Diagnosis of meningioma AND (2) Disease is surgically inaccessible AND (3) Disease is recurrent or progressive AND (4) Radiation is not possible

Authorization will be issued for 12 months

Meningioma reauthorization: Patient does not show evidence of progressive disease while on Sandostatin therapy

Authorization will be issued for 12 months

Neuroendocrine Tumors

Covered when criteria below are met

NET initial diagnosis: Diagnosis of a neuroendocrine tumor (includes carcinoid tumors, islet cell tumors, gastrinomas, glucagonomas, insulinomas, lung tumors, somatostatinomas, tumors of the pancreas, GI tract, lung, thymus, adrenal glands, and VIPomas)

Authorization will be issued for 12 months

NET subgroup: (a) Diagnosis of pheochromocytoma/paraganglioma OR well-differentiated grade 3 NET AND (b) disease is locally unresectable or metastatic

Authorization will be issued for 12 months

NET reauthorization: Patient does not show evidence of progressive disease while on Sandostatin therapy

Authorization will be issued for 12 months

Thymoma / Thymic Carcinoma

Covered when ALL of the following are met

Thymoma initial: (1) Diagnosis of thymoma or thymic carcinoma AND (2) either (a) used as second-line therapy for unresectable locally advanced disease or solitary/ipsilateral pleural metastasis OR (b) used as first-line therapy in specified potentially resectable or metastatic scenarios when the patient is unable to tolerate first-line combination regimens

Authorization will be issued for 12 months

Thymoma reauthorization: Patient does not show evidence of progressive disease while on Sandostatin therapy

Authorization will be issued for 12 months

Malignant Bowel Obstruction

Covered when ALL of the following are met

Malignant bowel obstruction initial: (1) Diagnosis of malignant bowel obstruction AND (2) Gut function cannot be maintained

Authorization will be issued for 12 months

Initial Therapy - Malignant Bowel Obstruction

Covered when ALL of the following are met

Malignant bowel obstruction initial: (1) Diagnosis of malignant bowel obstruction AND (2) Gut function cannot be maintained

Authorization will be issued for 12 months

Reauthorization - Malignant Bowel Obstruction

Reauthorization covered when the following is met

Malignant bowel obstruction reauth: Documentation of positive clinical response to Sandostatin therapy

Authorization will be issued for 12 months

Initial Therapy - Chemotherapy/Radiation-induced Diarrhea

Covered when ALL of the following are met (with one of two sub-conditions)

Chemo/radiation-induced diarrhea initial: (1) Diagnosis of diarrhea due to concurrent cancer chemotherapy and/or radiation AND (2) one of: (a) presence of Grade 3 or 4 severe diarrhea OR (b) patient is in palliative or end of life care

Authorization will be issued for 12 months

Reauthorization - Chemotherapy/Radiation-induced Diarrhea

Reauthorization covered when the following is met

Chemo/radiation-induced diarrhea reauth: Documentation of positive clinical response to Sandostatin therapy

Authorization will be issued for 12 months

Initial Therapy - Bleeding Gastroesophageal Varices

Covered when ALL of the following are met

Bleeding gastroesophageal varices initial: (1) Diagnosis of bleeding gastroesophageal varices associated with liver disease

Authorization will be issued for 12 months

Reauthorization - Bleeding Gastroesophageal Varices

Reauthorization covered when the following is met

Bleeding gastroesophageal varices reauth: Documentation of positive clinical response to Sandostatin therapy

NCCN Recommended Regimens

Covered when the following is met

NCCN-recognized regimens: Drug is recognized for treatment of the cancer indication by the NCCN Drugs and Biologics Compendium with a Category of Evidence and Consensus of 1, 2A, or 2B

Authorization period typically 12 months

The long‑acting release formulation Sandostatin LAR is not managed by this pharmacy prior authorization/notification policy. Only the subcutaneous formulation of octreotide (Sandostatin) requires pharmacy notification/PA; Sandostatin LAR is covered under the medical benefit and is addressed in the separate Somatostatin Analogs medical policy.

Per the policy change control effective in 4/2025, coverage criteria that previously addressed HIV/AIDS‑related diarrhea were removed and are no longer included in this pharmacy notification/PA policy. This revision aligns the policy with current clinical evidence and NCCN‑based updates described in the change history.

Historical change control notes summarize prior edits to coverage and reauthorization language, additions and removals of indications, and alignment with NCCN guidance. Past revisions include removing detailed chemotherapy/radiation and HIV/AIDS diarrhea language (11/2013), adding pediatric oncology age criteria and extending authorization periods (11/2015), multiple annual reviews with updates to meningioma, neuroendocrine tumor, and thymoma criteria, and the April 2025 updates that refined acromegaly and meningioma wording, added well‑differentiated grade 3 NET language, adjusted thymoma/thymic carcinoma criteria, and removed HIV/AIDS‑related diarrhea coverage.

Initial Therapy Criteria by Indication

Initial Therapy

Initial authorization requirements vary by indication; authorizations are typically for 12 months.

Pediatric oncology initial: Patient <19 years of age AND treatment is for an oncology indication

12-month authorization

Acromegaly initial: Diagnosis of acromegaly AND either inadequate response to surgical resection/pituitary irradiation/dopamine agonist therapy OR not a candidate for those treatments

12-month authorization

Meningioma initial: Diagnosis of meningioma AND surgically inaccessible AND recurrent or progressive disease AND radiation not possible

12-month authorization

Reauthorization / Continuation Therapy

Reauthorization conditions

Continuation criteria: Patient does not show evidence of progressive disease while on Sandostatin therapy OR documentation of positive clinical response (e.g., suppression of severe diarrhea, flushing)

Authorization will be issued for 12 months

Reauthorization / Continuation

Reauthorization/continuation requires documentation of benefit

Continuation therapy: Documentation of positive clinical response to Sandostatin therapy required for reauthorization; authorization will be issued for 12 months

Provider Requirements and Administrative Actions

Prior Authorization

State mandate override

Some states mandate benefit coverage for off-label use of medications for certain diagnoses or circumstances, or mandate the use of alternate compendium references. Where such state mandates apply, they supersede the language in this policy and related notification criteria. Providers should verify state-specific requirements when submitting requests.

Step Therapy

Acromegaly step requirements

For patients with acromegaly, initial authorization requires a diagnosis of acromegaly and documentation of inadequate response to surgery, pituitary irradiation, or dopamine agonist therapy (e.g., bromocriptine, cabergoline), OR documentation that the patient is not a candidate for those interventions. Authorization will be issued for 12 months.

Diagnosis: acromegaly
Step requirement: inadequate response to surgery, pituitary irradiation, or dopamine agonist therapy OR not a candidate for these therapies
Authorization duration: 12 months

Step Therapy and Failure Criteria

Step	Requirement
1	Acromegaly: prior to approval patient must have failed or be ineligible for surgery, pituitary irradiation, or dopamine agonist therapy (i.e., inadequate response to surgical resection, pituitary irradiation, or dopamine agonist such as bromocriptine or cabergoline; OR not a candidate for surgical resection, pituitary irradiation, or dopamine agonist therapy).
1	Thymoma / Thymic carcinoma: certain uses require prior intolerance or failure of first‑line combination regimens or meet the policy's specified second‑line/first‑line criteria (see thymoma criteria for details of required sequencing).

Program-level process	Operational note
Automated program rules may apply	UnitedHealthcare may approve initial and reauthorization requests based solely on previous claim/medication history, diagnosis codes (ICD‑10), and/or claim logic; use of automated approval and re‑approval processes varies by program and therapeutic class.

Background and Definitions

Octreotide acetate (Sandostatin) is a somatostatin analog that suppresses secretion of multiple hormones and peptides; clinically it is used to reduce growth hormone and IGF‑I levels in acromegaly and to control symptoms of neuroendocrine tumors such as carcinoid syndrome and VIPoma‑related diarrhea. NCCN guidance and the policy also recognize octreotide for other tumor types (including thymic tumors and certain meningiomas) and for palliative indications such as chemotherapy/radiation‑induced severe diarrhea and malignant bowel obstruction. The policy notes that long‑acting formulations (Sandostatin LAR) are managed under the medical benefit and that coverage decisions have been periodically updated to align with NCCN compendium recommendations.

Sandostatin LAR

DefinitionSandostatin LAR is the long-acting release formulation of octreotide (somatostatin analog) and is NOT addressed by this pharmacy policy; it is covered under the medical benefit and in a separate Somatostatin Analogs policy.

Formulation distinctionThis policy applies to the subcutaneous formulation of Sandostatin (octreotide acetate); long‑acting (LAR) formulation is managed under medical benefit.

Related policySee Somatostatin Analogs policy for coverage and medical‑benefit administration of Sandostatin LAR.

Coding and Billing Notes

Billing Rule

Billing/coding risk: insufficient diagnosis codes or claim history may trigger automated denial

Claims may be denied or delayed if submitted without sufficient diagnosis codes, prior claim/medication history, or required claim logic that automated rules use to approve prior authorization requests.

Include pertinent ICD‑10 diagnosis codes and prior treatment history when submitting authorization requests to reduce billing/coding denial risk.

OpenPayer

Prior authorization/notification — Sandostatin (octreotide acetate) subcutaneous

Coverage Criteria for Subcutaneous Octreotide (Sandostatin)

Initial Therapy Criteria by Indication

Reauthorization / Continuation Therapy

Provider Requirements and Administrative Actions

Step Therapy and Failure Criteria

Background and Definitions

Coding and Billing Notes