By Counterforce Health Team in Signifor / Signifor LAR (pasireotide) —

Get Signifor LAR (Pasireotide) Covered by Blue Cross Blue Shield in Florida: 2025 Prior Authorization Guide

Quick Answer: Your Path to Coverage

Yes, Florida Blue covers Signifor LAR (pasireotide) for Cushing's disease and acromegaly, but requires prior authorization. The fastest path: ensure your endocrinologist has documented failed surgery or contraindications, recent labs (UFC for Cushing's, IGF-1 for acromegaly), and baseline tests within 6 months. Submit via Florida Blue's provider portal or the Signifor LAR PA form. First step today: call your doctor to verify you have all required documentation, then request they submit the PA immediately.

Table of Contents

  1. How to Use This Guide
  2. Eligibility Quick Check
  3. If You're Likely Eligible
  4. If You're Possibly Eligible
  5. If You're Not Yet Eligible
  6. If Your Request Gets Denied
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & How to Fix Them
  9. Appeals Process for Florida Blue
  10. Frequently Asked Questions
  11. When to Get Help

How to Use This Guide

This decision tree helps you determine your likelihood of getting Signifor LAR covered by Florida Blue Cross Blue Shield and maps out your next steps. Start with the eligibility check below, then follow the appropriate pathway.

Important: Signifor LAR costs over $20,000 per vial, making prior authorization essential. Florida Blue requires specific documentation and follows strict criteria outlined in their MCG policy 09-J1000-94.

Eligibility Quick Check

Answer these questions to determine your approval likelihood:

For Cushing's Disease:

  • Do you have a confirmed diagnosis of Cushing's disease?
  • Has pituitary surgery failed or are you not a surgical candidate?
  • Do you have recent urinary free cortisol (UFC) results?
  • Are your baseline tests current (within 6 months): glucose, HbA1c, liver function, electrolytes, ECG, gallbladder ultrasound?
  • Is your prescriber an endocrinologist?

For Acromegaly:

  • Do you have confirmed acromegaly diagnosis?
  • Have you failed or have contraindications to at least one first-generation somatostatin analog (octreotide LAR or lanreotide)?
  • Do you have elevated IGF-1 levels (age/sex adjusted)?
  • Are your baseline tests current?
  • Is your prescriber an endocrinologist?

Results:

  • 4-5 boxes checked: Likely eligible → Go to section 3
  • 2-3 boxes checked: Possibly eligible → Go to section 4
  • 0-1 boxes checked: Not yet eligible → Go to section 5

If You're Likely Eligible

You have strong chances for approval. Here's your submission checklist:

Required Documentation

  1. Diagnosis confirmation with ICD-10 codes
  2. Surgical history documenting failure or contraindications
  3. Laboratory results (within 30 days):
    • Cushing's: 24-hour urinary free cortisol
    • Acromegaly: IGF-1 with age/sex reference ranges
  4. Baseline safety tests (within 6 months):
    • Fasting glucose and HbA1c
    • Complete metabolic panel
    • Liver function tests
    • ECG
    • Gallbladder ultrasound
  5. Prior therapy documentation (for acromegaly)
  6. Prescriber attestation from board-certified endocrinologist

Submission Process

  1. Download the form: Get the Signifor LAR Prior Authorization Form
  2. Complete thoroughly: Include all required fields and attach supporting documents
  3. Submit via preferred method:
    • Online: Florida Blue provider portal (fastest)
    • Fax: 1-877-219-9448 (standard PA fax line)
  4. Follow up: Call within 3 business days to confirm receipt
Tip: Online submissions typically process 21-28 days faster than fax submissions.

If You're Possibly Eligible

You need additional documentation before submitting. Focus on these areas:

Missing Pieces to Address

  • Get specialist referral: If not seeing an endocrinologist, request referral immediately
  • Complete lab work: Order missing tests (UFC, IGF-1, baseline safety panel)
  • Document prior therapies: For acromegaly, ensure clear records of octreotide or lanreotide trial and failure
  • Surgical consultation: If surgery hasn't been considered, get neurosurgical evaluation

Timeline to Resubmit

  • Lab results: 1-2 weeks
  • Specialist appointment: 2-8 weeks (varies by availability)
  • Surgical consultation: 4-12 weeks

Track your progress and resubmit once you have 4-5 eligibility criteria met.

If You're Not Yet Eligible

Don't lose hope. Here are your options:

Alternative Treatments to Discuss

For Cushing's Disease:

  • Osilodrostat (Isturisa)
  • Mifepristone (Korlym)
  • Pituitary surgery evaluation
  • Radiation therapy consultation

For Acromegaly:

  • First-generation somatostatin analogs (octreotide LAR, lanreotide)
  • Pegvisomant (Somavert)
  • Dopamine agonists (cabergoline)

Preparing for Future Exception Request

  1. Document everything: Keep detailed records of treatment trials and outcomes
  2. Build your case: Work with your endocrinologist to establish medical necessity
  3. Consider clinical trials: May provide access while building documentation

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned to your plan's specific rules, potentially saving months of back-and-forth with your insurer.

Coverage Requirements at a Glance

Requirement Cushing's Disease Acromegaly Where to Find
Prior Authorization Required Required Florida Blue PA page
Prescriber Board-certified endocrinologist Board-certified endocrinologist Provider directory
Key Labs 24-hour UFC IGF-1 (age/sex adjusted) Lab orders from physician
Prior Therapy Surgery attempted/contraindicated Failed octreotide/lanreotide Medical records
Dosing Limit ≤40 mg every 4 weeks ≤60 mg every 4 weeks MCG Policy
Approval Duration 6 months initial, 1 year renewal 6 months initial, 1 year renewal Policy document

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Non-specialist prescriber Transfer care to endocrinologist Board certification verification
Missing baseline labs Complete safety testing Glucose, liver function, ECG, gallbladder US
Inadequate prior therapy Document trials and failures Pharmacy records, provider notes
Dosing exceeds limits Justify with FDA labeling Prescriber letter with clinical rationale
Surgery not attempted Get neurosurgical evaluation Consultation notes documenting contraindications

Appeals Process for Florida Blue

If your prior authorization gets denied, Florida has strengthened appeal rights under the 2024 Patient Timely Access to Healthcare Act.

Internal Appeal (First Level)

  • Deadline: 180 days from denial notice
  • Timeline: Florida Blue must respond within 30 days (down from previous 47-day average)
  • How to submit: Use Florida Blue's Reconsideration Request Form
  • Include: Point-by-point rebuttal, additional medical records, specialist letter

Peer-to-Peer Review

  • When: Before or during formal appeal
  • Process: Your doctor discusses case directly with Florida Blue medical director
  • Request: Through provider portal or by calling number on denial letter
  • Advantage: Often resolves issues without formal appeal

External Review

  • Eligibility: After internal appeal exhaustion
  • Timeline: 45 days standard, 72 hours expedited
  • Cost: Free to patient
  • How to file: Contact Florida Department of Financial Services at 1-877-MY-FL-CFO
  • Success rate: Approximately 25-40% of external reviews overturn insurer denials
Note: For urgent cases involving severe symptoms, you can request expedited review at any level, with decisions required within 72 hours.

Frequently Asked Questions

How long does Florida Blue prior authorization take? Standard requests: 15 calendar days. Urgent requests: 72 hours. Submit online through the provider portal for faster processing.

What if Signifor LAR is non-formulary on my plan? It may still be covered through the prior authorization process. Florida Blue evaluates medical necessity regardless of formulary status for specialty medications.

Can I get a temporary supply while waiting for approval? Yes, for urgent cases. Your doctor can request a 72-hour emergency supply while the PA processes. Document the urgent medical need clearly.

Does step therapy apply if I tried octreotide with my previous insurer? Under Florida law (HB 459), step therapy requirements may be waived if you were approved for the drug under a prior plan within 90 days, with proper documentation.

What counts as "failed" prior therapy for acromegaly? Inadequate biochemical control (IGF-1 remains elevated), intolerable side effects, or contraindications to first-generation somatostatin analogs must be documented with specific dates and outcomes.

How much will I pay out-of-pocket? Depends on your specific plan. Check your benefits summary for specialty drug coverage. Recordati offers patient assistance programs that may help with copays.

Can I appeal if my doctor isn't an endocrinologist? You can request a formulary exception, but approval is unlikely. It's more effective to establish care with an endocrinologist first.

What happens if I miss the appeal deadline? Contact Florida's Insurance Consumer Helpline at 1-877-MY-FL-CFO immediately. They may help if you can document extenuating circumstances.

When to Get Help

Consider professional assistance if:

  • You've been denied twice
  • Your case involves complex medical history
  • You're facing urgent health needs
  • You're uncomfortable navigating the appeals process

Florida Resources:

For complex denials involving specialty medications like Signifor LAR, companies like Counterforce Health provide specialized expertise in crafting evidence-backed appeals that address payer-specific requirements and increase approval odds.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by individual plan. Always verify current requirements with Florida Blue and consult your healthcare provider for medical decisions.

Sources & Further Reading

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