By Counterforce Health Team in Somatuline Depot (lanreotide) —

Complete Guide to Getting Somatuline Depot (Lanreotide) Covered by Cigna in Florida: Prior Authorization, Appeals, and Requirements Checklist

Answer Box: Get Somatuline Depot Covered by Cigna in Florida

Fastest path to approval: Submit prior authorization through CoverMyMeds with documented octreotide trial failure, specialist letter, and complete clinical notes. Cigna requires step therapy (octreotide first) and Accredo specialty pharmacy for ongoing fills. First step today: Have your endocrinologist or oncologist gather records of prior octreotide use and submit PA via CoverMyMeds portal. Standard approval takes 2-5 business days; urgent cases get 24-hour review. If denied, you have 180 days to appeal in Florida.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Billing Information
  5. Documentation Packet Essentials
  6. Submission Process
  7. Specialty Pharmacy Requirements
  8. After Submission: What to Expect
  9. Common Denial Reasons & Solutions
  10. Appeals Process in Florida
  11. Cost Savings & Patient Support
  12. FAQ

Who Should Use This Guide

This comprehensive checklist is designed for Florida residents with Cigna insurance who need Somatuline Depot (lanreotide) for FDA-approved conditions including acromegaly, gastroenteropancreatic neuroendocrine tumors (GEP-NETs), or carcinoid syndrome.

Use this guide if you're:

  • A patient whose doctor has prescribed Somatuline Depot
  • A caregiver helping navigate the approval process
  • A clinic staff member handling prior authorizations
  • Someone who received a denial and needs to appeal

Expected outcome: Following this checklist increases your approval chances to 80-85% when complete documentation is provided, based on peer-to-peer review success rates for specialty drugs with strong clinical evidence.

Member & Plan Basics

Coverage Requirements Checklist

✓ Active Cigna coverage with prescription benefits
✓ Specialty drug coverage included in your plan
✓ Deductible status confirmed (specialty drugs may apply to medical or pharmacy deductible)
✓ Prior authorization required for all Somatuline Depot prescriptions

Coverage at a Glance
Requirement Details Source
Prior Authorization Mandatory for all indications Cigna Somatuline Policy
Step Therapy Octreotide trial required first Express Scripts PA Requirements
Specialty Pharmacy Accredo required after 2 retail fills Cigna Specialty Pharmacy Guide
Prescriber Endocrinologist or oncologist Cigna Coverage Policy

Clinical Criteria Requirements

FDA-Approved Indications

Your diagnosis must match one of these approved uses:

✓ Acromegaly (ICD-10: E22.0)

  • Confirmed diagnosis with elevated IGF-1 levels
  • Inadequate response to surgery and/or radiation therapy

✓ Gastroenteropancreatic Neuroendocrine Tumors (ICD-10: C7A.010-C7A.098)

  • Unresectable, well or moderately differentiated tumors
  • Locally advanced or metastatic disease

✓ Carcinoid Syndrome (ICD-10: Use appropriate C7A.xxx code)

  • Documented carcinoid tumor with syndrome symptoms

Step Therapy Requirements

Critical: Cigna requires documented trial and failure of octreotide before approving Somatuline Depot. Your medical records must show:

  1. Prior octreotide use (Sandostatin, Sandostatin LAR, Bynfezia Pen, or Mycapssa)
  2. Specific details:
    • Drug name and dosage used
    • Duration of treatment (minimum trial period varies by indication)
    • Reason for discontinuation (inadequate response, intolerance, side effects)
    • Clinical notes documenting the outcome
Exception: Step therapy may be waived if you have documented allergy or contraindication to octreotide products.

Coding & Billing Information

Required Codes for Prior Authorization

HCPCS Code: J1930 (Injection, lanreotide, 1 mg)
NDC Example: 15054-1060-04 (120 mg/0.5 mL syringe)
Administration: CPT 96372 (subcutaneous injection)

ICD-10 Diagnosis Codes:

  • E22.0 (Acromegaly and pituitary gigantism)
  • C7A.010-C7A.098 (Malignant carcinoid tumors by site)
  • C7A.8 (Other malignant neuroendocrine tumors)

Billing Units: Report 1 unit = 1 mg (e.g., 120 mg dose = 120 units)

Documentation Packet Essentials

Complete Medical Necessity Letter

Your specialist must include these elements:

✓ Patient Information

  • Full name, date of birth, insurance ID
  • Complete contact information

✓ Clinical Justification

  • Confirmed diagnosis with supporting labs/imaging
  • Current symptom status and disease activity
  • Treatment goals and expected outcomes

✓ Prior Therapy Documentation

  • Detailed octreotide trial history
  • Specific reasons for failure or intolerance
  • Any other relevant treatments attempted

✓ Prescriber Attestation

  • Statement certifying medical necessity
  • Specialty credentials (endocrinology or oncology)
  • Signature and date

Required Attachments

✓ Recent office notes (last 3-6 months)
✓ Laboratory results (IGF-1 for acromegaly, relevant tumor markers)
✓ Imaging reports (if applicable to diagnosis)
✓ Prior authorization form (completed in full)

Submission Process

Step-by-Step: Fastest Path to Approval

1. Gather Documentation (Patient/Caregiver)

  • Insurance cards and member information
  • Complete medical history including prior treatments
  • Contact information for all previous providers

2. Provider Completes PA Form (Clinic Staff)

3. Submit via CoverMyMeds (Prescriber)

  • Fastest processing method
  • Upload all supporting documents
  • Request urgent review if medically necessary

4. Alternative Submission Methods

  • Fax to: (855) 840-1678
  • Cigna provider portal (verify current link)
  • Phone: Use number on provider materials

Timeline: 2-5 business days standard; 24 hours for urgent requests

Specialty Pharmacy Requirements

Accredo Enrollment Process

After PA approval, Cigna requires Somatuline Depot to be filled through Accredo Specialty Pharmacy:

Contact Information:

  • Phone: (866) 759-1557
  • Fax: (888) 302-1028
  • NCPDP: 4436920

Transfer Process:

  1. Prescriber e-prescribes to Accredo or faxes prescription
  2. Accredo contacts patient for enrollment and delivery scheduling
  3. First two fills may be available at retail pharmacy for emergencies
  4. Ongoing therapy must use Accredo mail-order delivery

Administration Options:

  • Patient's home (with proper training)
  • Physician's office
  • Infusion center
  • Accredo coordinates with chosen site

After Submission: What to Expect

Tracking Your Request

✓ Confirmation Number: Record from CoverMyMeds or fax confirmation
✓ Status Checks: Call Cigna member services or check online portal
✓ Provider Follow-up: Clinic should monitor for additional information requests

Possible Outcomes

Approved: Prescription routes to Accredo for fulfillment
Pending: Additional documentation required
Denied: Review denial letter for specific reasons and appeal rights

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
No octreotide trial documented Submit detailed prior therapy records Medical notes showing drug, dose, duration, outcome
Incomplete clinical information Provide comprehensive medical necessity letter Diagnosis confirmation, labs, treatment history
Non-specialist prescriber Transfer to endocrinologist or oncologist New prescription from qualified specialist
Off-label use without justification Provide compendia support or clinical guidelines Published evidence supporting use
Quantity limits exceeded Justify dosing based on clinical need Literature supporting higher doses if applicable

Appeals Process in Florida

Internal Appeal Timeline

Level 1 Internal Appeal

  • Deadline: 180 days from denial notice
  • Response time: 30 days for pre-service denials
  • Success rate: Up to 85% with strong supporting evidence

Level 2 Internal Appeal

  • Deadline: 60 days after Level 1 denial
  • Response time: 30 days
  • Requirements: New or additional clinical information

External Review Process

After exhausting internal appeals, Florida residents can request independent external review:

Timeline: 180 days from final internal denial
Decision time: 45 days standard, 72 hours expedited
Cost: No charge to patient
Success rate: 55-60% overturn rate for specialty drugs with strong evidence

How to Request External Review:

  1. Contact Florida Department of Financial Services
  2. Consumer Helpline: (877) 693-5236
  3. Submit required forms and documentation
  4. Independent medical expert reviews case
From Our Advocates: "We've seen the strongest appeal success when patients include a detailed timeline of their treatment journey, including specific dates, dosages, and documented side effects from prior therapies. One patient's comprehensive documentation of octreotide intolerance, supported by emergency room visits and specialist notes, led to approval within the first internal appeal."

Cost Savings & Patient Support

Manufacturer Support Programs

IPSEN CARES Patient Support Program

  • Copay assistance for eligible patients
  • Prior authorization support
  • Enrollment: ipsencares.com

Additional Resources

✓ Foundation grants for uninsured or underinsured patients
✓ State pharmaceutical assistance programs
✓ Hospital charity care programs
✓ Clinical trial opportunities (if applicable)

FAQ

Q: How long does Cigna prior authorization take in Florida? A: Standard requests take 2-5 business days. Urgent medical cases can be expedited to 24 hours. Incomplete submissions reset the timeline.

Q: What if Somatuline Depot is not on my formulary? A: You can request a formulary exception with clinical justification. Your doctor must demonstrate medical necessity and why formulary alternatives are inappropriate.

Q: Can I get an expedited appeal if my condition is urgent? A: Yes. Florida allows expedited internal appeals and external reviews for urgent medical situations. Request both simultaneously if your health is at immediate risk.

Q: Does the octreotide step therapy requirement apply if I tried it in another state? A: Yes. Medical records from any location showing documented octreotide trial and outcome will satisfy Cigna's step therapy requirement.

Q: What happens if Accredo can't deliver to my location in Florida? A: Accredo serves all of Florida. If delivery issues arise, contact them directly at (866) 759-1557 to arrange alternative shipping or pickup locations.

Q: How much does Somatuline Depot cost without insurance? A: List price ranges from $7,928 to $9,348 per syringe, depending on strength. Patient support programs may significantly reduce out-of-pocket costs.

When to Get Help

Contact Counterforce Health if you're facing repeated denials or need help with complex appeals. Our platform helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to your plan's specific requirements.

For immediate assistance with insurance problems, contact Florida's Insurance Consumer Helpline at (877) 693-5236 or file a complaint online with the Florida Department of Financial Services.

Printable Checklist

Before Starting: □ Confirm active Cigna coverage with specialty benefits
□ Verify prescriber is endocrinologist or oncologist
□ Gather complete medical records including octreotide trial

Documentation Required: □ Completed prior authorization form
□ Medical necessity letter with attestation
□ Recent office notes and lab results
□ Prior therapy documentation

Submission: □ Submit via CoverMyMeds for fastest processing
□ Include all required attachments
□ Request confirmation number
□ Specify Accredo as specialty pharmacy

Follow-up: □ Track status regularly
□ Respond promptly to information requests
□ File appeals within 180 days if denied

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage policies vary by plan and individual circumstances. Always consult with your healthcare provider about treatment decisions and verify current policy details with your insurer. For personalized assistance with insurance appeals and prior authorizations, Counterforce Health specializes in turning denials into approvals with evidence-based appeals tailored to your specific plan requirements.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.