ICD-10 — FDA-labeled indications
| Code | For |
|---|
E22.0 | Acromegaly (pair w/ IGF-1, GH evidence + endo consult) |
C7A.1 | Malignant NET, pancreas (pNET) |
C7A.010–012 | Malignant carcinoid, small intestine (midgut) |
C7A.020–029 | Carcinoid: cecum / appendix / colon / rectum |
C7A.090/091 | Bronchopulmonary carcinoid (typ / atyp) |
C7B.0x–C7B.8 | Secondary NET (liver mets C7B.02; etc.) — pair w/ primary |
E34.0 | Carcinoid syndrome — pair w/ malignant C-code primary |
NET = G1/G2 only. Ki-67 ≤20% on path. G3 disease generally off-label for SSA monotherapy.
Somatuline vs Sandostatin LAR
| Aspect | Somatuline J1930 | Sandostatin LAR J2353 |
|---|
| Generic | lanreotide (Ipsen) | octreotide (Novartis) |
| Route | Deep SC, buttock | Deep gluteal IM |
| Prep | Ready-to-use prefilled syringe | Microsphere reconstitution |
| Unit | 1 mg = 1 unit | 1 mg = 1 unit |
| Strengths | 60 / 90 / 120 mg | 10 / 20 / 30 mg |
| Cadence | q4w | q4w |
Step therapy: some plans prefer one SSA over the other per rebate. Verify formulary before initiating.
Payer requirements (May 2026)
| Payer | PA | Notes |
|---|
| UnitedHealthcare | Yes | NET: Ki-67, CgA, imaging, onc consult. Acromegaly: IGF-1, GH, MRI, endo consult. |
| Aetna | Yes | Same as UHC; site-of-care UM HOPD |
| Cigna | Yes | NCCN-aligned NET; step possible |
| BCBS plans | Yes | Plan-specific SSA preference |
| Medicare MACs | Generally no | FDA-labeled indication + ICD-10 |
| Medicaid | Yes | State PDL varies |
Medicare reimbursement (Q2 2026)
| Field | Value |
|---|
| ASP + 6% per mg | $35.722 (Apr 1 – Jun 30, 2026) |
| 60 mg dose (60 units) | $2,143.32 |
| 90 mg dose (90 units) | $3,214.98 |
| 120 mg dose (120 units) | $4,286.64 |
| Annual 120 mg q4w (13 doses) | ~$55,726 / yr drug |
| After ~2% sequestration | ~$54,612 / yr |
| Next CMS update | July 1, 2026 (Q3) |
Patient assistance — IPSEN CARES
- IPSEN CARES: 1-866-435-5677 — BI, PA, appeals, copay, PAP, bridge supply
- Copay (commercial only): as low as $0/dose for eligible commercial-insured (excludes federal); annual cap per terms
- PAP (free drug): uninsured / income-qualified (typically ≤500% FPL — verify current threshold)
- Bridge / quickstart: while coverage is established
- Federal patients (Medicare/Medicaid/TRICARE/VA): PAN, HealthWell, CancerCare, NORD
- Web: ipsencares.com · somatulinedepot.com
Top denials: (1) wrong admin CPT (96372 instead of 96401 for GEP-NET); (2) NET PA missing Ki-67 / histology; (3) acromegaly PA missing IGF-1; (4) HOPD site-of-care steerage after stabilization.