Medicare AdvantagePrior AuthMedium impact
Mycapssa® (octreotide) delayed-release capsules (Revised)
Humana·Endocrinology, Internal Medicine·Medicare Advantage
Effective date
Nov 26, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has revised its prior authorization policy for Mycapssa® (octreotide) delayed-release capsules for acromegaly treatment, effective November 26, 2025. The policy requires prior authorization and mandates that patients must be established on baseline octreotide or lanreotide, have demonstrated response to therapy (IGF-1 within normal limits), and have tolerated prior therapy before Mycapssa approval. Initial and renewal approvals are granted in plan year durations or through clinical review.
Action Required
By November 26, 2025: Billing team must implement prior authorization requirements for all Mycapssa (octreotide) delayed-release capsule claims for Medicare Advantage members. Update billing software to flag these claims as requiring prior authorization before submission. Providers must submit documentation confirming: (1) acromegaly diagnosis, (2) patient established on baseline octreotide or lanreotide, (3) evidence of treatment response (IGF-1 levels within normal limits), and (4) patient tolerance of prior therapy. Claims submitted without prior authorization or incomplete documentation will be denied. Update encounter forms and billing templates to include reminder fields for these four approval criteria. Contact Humana directly for any questions about clinical review determinations beyond the stated criteria.