Reimbursement Guide
For an overview of coverage for Sandostatin® LAR Depot (octreotide acetate for injectable suspension), see:
For more detailed information about insurance coverage, see:
- Coverage of Initial Therapy with Immediate Release Sandostatin® (octreotide acetate) Injection
- Coverage of Long-term Therapy with Sandostatin® LAR Depot
- Appealing Denied Claims
Reimbursement for Sandostatin® LAR Depot depends on the insurer. For most patients, the cost of medical therapy is shared through co-payments and insurance deductibles. To learn more about reimbursement for Sandostatin® LAR Depot, see:
Sandostatin® LAR Depot Coverage at a Glance
To understand your patient's coverage, you need to know that:
- Most private medical insurance plans will cover for immediate release Sandostatin® Injection and Sandostatin® LAR Depot through a patient's pharmacy benefit
- Patients without a pharmacy benefit through their primary insurer should determine whether they have coverage for immediate release Sandostatin® Injection through secondary insurance
- Generally, Medicaid does provide coverage for immediate release Sandostatin® Injection
- Medicare does not provide coverage for self-administered injectable therapy
Coverage of Initial Therapy with Immediate Release Sandostatin® Injection
Most private medical insurance plans will cover immediate release Sandostatin® Injection through a patient's pharmacy benefit. Patients who do not have a pharmacy benefit through their primary insurer should determine whether they have coverage for immediate release Sandostatin® Injection through secondary insurance. The Sandostatin® Therapy Support Hotline (1-877-LAR-HELP) can assist you in determining a patient's insurance coverage for immediate release Sandostatin® Injection.
Medicare does not provide coverage for self-administered injectable therapy. To assist some of these patients, as well as to assist some patients who do not have a prescription drug benefit, Novartis has set up the Sandostatin® Starter Program, a complimentary program that provides 2 to 4 weeks of immediate release Sandostatin® Injection.
Download an application form (PDF 100KB).
Coverage of Long-term Therapy with Sandostatin® LAR Depot
Private insurers and Medicare generally cover medically necessary drugs provided in the physician's office and outpatient clinic settings. However, some plans may have special requirements as to how the drug should be purchased, or what kind of provider should inject it.
The Sandostatin® Therapy Support Hotline can help healthcare professionals determine plan-specific coverage, referrals, prior authorization, and reimbursement policies.
Appealing Denied Claims
Insurers may deny claims for a variety of reasons. Often, physicians can successfully appeal denied claims if the treatment is medically necessary. To help prevent inappropriately denied claims, it is suggested that the prescriber contact the patient's insurer to determine if letters of medical necessity and/or prior authorization are required before administering the product. The Hotline can assist you with this step.
To appeal a denied claim, follow these steps:
Step 1.
Carefully review the patient's explanation of benefits (EOB) from the insurer. Often claims are denied because of missing identification numbers, patient names, or signatures.
Step 2.
If you have ruled out claims submission errors, you may need to support the claim by documenting medical necessity. Insurers may deny coverage if they are not familiar with Sandostatin® LAR Depot. Resubmit the claim with a letter of medical necessity that highlights the following:
- The patient's medical history
- Other therapies that have been tried
- The reason Sandostatin® LAR Depot was prescribed for this patient
- The risks of foregoing Sandostatin® LAR Depot treatment
- A Sandostatin® LAR Depot package insert (PDF 332KB)
- Peer-reviewed articles concerning the use of Sandostatin® LAR Depot
- An invoice
Step 3.
If a second claim is denied, the Sandostatin® Therapy Support Hotline, at 1-877-LAR-HELP, can assist you in following up with insurers and submitting the necessary documentation. You may also advise the patient to call the insurer to request a hearing.
Step 4.
Encourage patients to contact their benefits office regarding denied claims and talk to the benefits manager, if necessary. Remember that many efforts to pursue coverage and payment are successful, although the process may be lengthy.
Important Safety Information
Carcinoid Syndrome:
Sandostatin® LAR Depot (octreotide acetate for injectable suspension) is indicated for long-term treatment of the severe diarrhea and flushing episodes associated with metastatic carcinoid tumors and for the long-term treatment of the profuse watery diarrhea associated with VIP-secreting tumors in patients in whom initial treatment with immediate release Sandostatin® (octreotide acetate) Injection has been shown to be effective and tolerated.
Important Safety Information:
As with immediate release Sandostatin® Injection, the most frequently reported drug-related adverse events were biliary disorders (62%), gastrointestinal disorders (14% to 38%), and injection-site pain (20% to 50%). Hypoglycemia (4%), hyperglycemia (27%), sinus bradycardia (19%), conduction abnormalities (9%), and arrhythmias (3%) have been reported.
The controlled clinical trials that support the marketing clearance for Sandostatin® LAR Depot did not include determination of effect on tumor size or rate of growth. Sandostatin® LAR Depot is not indicated for tumor shrinkage.
Acromegaly
Sandostatin® LAR Depot (octreotide acetate for injectable suspension) is indicated for long-term maintenance therapy in acromegalic patients who have had an inadequate response to surgery and/or radiotherapy, or for whom surgery and/or radiotherapy is not an option. The goal of treatment in acromegaly is to reduce GH and IGF-1 levels to normal.
Important Safety Information:
As with immediate release Sandostatin® Injection, the most frequently reported drug-related adverse events were biliary disorders (52%), gastrointestinal disorders (7% to 36%), and injection-site pain (2% to 11%). Hypoglycemia (2%), hyperglycemia (15%), and hypothyroidism (2%) have been reported. While not measured in acromegalic patients receiving Sandostatin® LAR Depot, ECG changes have been reported in patients receiving immediate release Sandostatin® Injection; the degree to which these abnormalities are related to octreotide acetate is not clear, as many acromegalics have cardiovascular disease. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.
