By Counterforce Health Team in Somatuline Depot (lanreotide) —

How Long Does It Take to Get Somatuline Depot (Lanreotide) Approved by Aetna CVS Health in New York? Complete Timeline Guide

Answer Box: Getting Somatuline Depot Approved by Aetna CVS Health in New York

Aetna CVS Health requires prior authorization for Somatuline Depot (lanreotide) with typical processing taking 2-45 days depending on submission method and completeness. Electronic submissions via Availity process fastest (24-72 hours), while standard requests take 30-45 days. First step: Have your endocrinologist or oncologist gather documentation of failed octreotide trial and submit PA request at least 2 weeks before treatment start. If denied, you have 180 days for internal appeal and 4 months for New York external review.

Table of Contents

  1. What Affects Approval Timing
  2. Pre-Submission Preparation (0-2 Days)
  3. Submission to Initial Review (1-5 Days)
  4. Additional Information Requests (1-7 Days)
  5. Decision Window & Typical Outcomes
  6. If Denied: Appeal Timelines
  7. Renewal Cycles & Re-Authorization
  8. Timeline Visual & Milestones
  9. Time-Saving Tips
  10. Common Denial Reasons & Solutions
  11. New York External Appeal Process

What Affects Approval Timing

Several factors influence how quickly Aetna CVS Health approves Somatuline Depot (lanreotide) in New York:

Benefit Type & Plan Design

  • Commercial plans: Standard 30-45 days, expedited 24-72 hours
  • Medicare Advantage: Similar timelines with 72-hour expedited option
  • Medicaid managed care: May have different review pathways

Complexity of Medical Criteria Somatuline Depot typically requires documentation of:

  • FDA-approved indication (acromegaly, GEP-NET, carcinoid syndrome)
  • Prior octreotide trial failure or contraindication (step therapy)
  • Specialist prescriber (endocrinologist or oncologist)
  • Appropriate dosing schedule (every 4 weeks)

Documentation Completeness Complete submissions process faster than those requiring additional information. CVS Specialty Pharmacy reports that incomplete requests add 2-7 days to processing time.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Clinical Records Required:

  • Confirmed diagnosis with ICD-10 codes
  • Lab results (IGF-1 levels for acromegaly, tumor markers for NET)
  • Imaging studies showing tumor burden
  • Documentation of octreotide trial with specific dates and outcomes
  • Specialist consultation notes

Insurance Information:

  • Current Aetna member ID and group number
  • Formulary status verification
  • Prior authorization form completion

Prescriber Requirements: Your specialist must be prepared to provide:

  • Medical necessity letter explaining why Somatuline Depot is preferred
  • Clinical rationale for dosing frequency
  • Treatment goals and monitoring plan
Tip: Call CVS Specialty at 1-800-237-2767 to verify your plan's specific requirements before submission.

Submission to Initial Review (1-5 Days)

Submission Methods & Processing Times

Method Timeline Best For
Availity Portal 24-72 hours Electronic submissions
CVS Caremark ePA 2 business days Integrated EMR systems
Fax (1-800-323-2445) 3-5 business days Paper-based offices
Phone (1-855-344-0930) Same day start Urgent situations

What Reviewers Check First:

  1. Member eligibility and benefits verification
  2. Prescriber credentials and specialty
  3. FDA indication match with diagnosis
  4. Step therapy compliance (octreotide trial)
  5. Quantity limits (one syringe per 28 days)

New York's insurance regulations require Aetna to acknowledge receipt within 24 hours and provide initial determination within their published timeframes.

Additional Information Requests (1-7 Days)

If Aetna requests additional information, respond quickly to avoid delays:

Common Information Requests:

  • More detailed octreotide trial documentation
  • Specialist consultation notes
  • Recent lab values or imaging
  • Insurance verification updates

How to Respond Efficiently:

  • Submit via the same method as original request
  • Include original PA reference number
  • Provide complete documentation rather than partial responses
  • Follow up within 48 hours to confirm receipt
Note: CVS Specialty can assist in gathering missing documentation and coordinating with your provider.

Decision Window & Typical Outcomes

Standard Processing Times

  • Electronic submissions: 24-72 hours for complete requests
  • Standard submissions: 30-45 days maximum
  • Expedited reviews: 72 hours when medical urgency documented

Reading Your Approval Letter

Approved requests will specify:

  • Approved quantity (typically one syringe per 28 days)
  • Duration of approval (usually 6-12 months)
  • Site of care restrictions (if any)
  • Renewal requirements

Partial Approvals

Sometimes Aetna approves with modifications:

  • Different strength than requested
  • Quantity limit adjustments
  • Additional monitoring requirements

If Denied: Appeal Timelines

Internal Appeal Process

You have 180 days from denial to file an internal appeal with Aetna:

Standard Internal Appeal:

  • Timeline: 30 days for decision
  • Submit via Availity portal or fax
  • Include additional medical evidence

Expedited Internal Appeal:

  • Timeline: 72 hours for decision
  • Required when delay would seriously jeopardize health
  • Physician attestation of urgency needed

External Appeal Rights in New York

After internal appeal denial, you have 4 months to request external review through the New York State Department of Financial Services:

  • Standard external appeal: 30-day decision
  • Expedited external appeal: 72 hours (24 hours for non-formulary drugs)
  • Cost: Maximum $25 (waived for financial hardship)
  • Decision: Binding on Aetna

Renewal Cycles & Re-Authorization

When to Re-Authorize

Most Somatuline Depot approvals require renewal every 6-12 months. Start the renewal process 30-45 days before expiration.

What Speeds Renewals

  • Documented clinical response (normalized IGF-1, stable tumor markers)
  • Adherence to treatment schedule
  • Continued specialist oversight
  • Updated lab values showing efficacy

Renewal Documentation

Your specialist should provide:

  • Treatment response assessment
  • Current lab results
  • Continued medical necessity
  • Any dosing adjustments needed

Timeline Milestones

Complete Timeline Overview

Phase Days Key Activities Success Factors
Preparation 0-2 Gather documents, verify coverage Complete clinical records
Submission 1-5 Submit PA request Electronic submission preferred
Initial Review 2-45 Aetna medical review Step therapy compliance
Additional Info 1-7 Respond to requests Quick, complete responses
Decision Same day Approval/denial issued Monitor portal daily
Appeal (if needed) 30-180 Internal/external appeal Strong medical evidence

Total Expected Timeline: 7-60 days for initial approval, depending on submission method and completeness.

Time-Saving Tips

Portal Usage Best Practices

  • Use Availity for fastest processing
  • Submit during business hours (Monday-Friday)
  • Upload all documents in single submission
  • Save confirmation numbers for tracking

Bundled Evidence Strategy

Submit comprehensive documentation upfront:

  • Complete medical history
  • All relevant lab results
  • Specialist consultation notes
  • Prior therapy documentation
  • Treatment plan outline

Direct Specialty Routing

  • Ensure prescriber is recognized specialist
  • Include specialty credentials in submission
  • Reference relevant treatment guidelines
  • Highlight FDA-approved indication
From our advocates: We've seen cases where providers who submitted complete octreotide failure documentation with specific dates and adverse effects got approved within 48 hours electronically, while incomplete submissions took weeks of back-and-forth requests.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
No octreotide trial Document prior therapy Dates, doses, duration, failure reason
Off-label use Provide clinical rationale Medical literature, specialist letter
Non-specialist prescriber Transfer to specialist Endocrinologist or oncologist
Quantity limits Justify dosing schedule FDA labeling, clinical guidelines
Non-formulary status Request formulary exception Medical necessity letter

New York External Appeal Process

If Aetna denies your internal appeal, New York offers robust external review rights:

Filing Requirements

  • Must complete internal appeal first
  • File within 4 months of final denial
  • Submit via DFS online portal
  • Include physician attestation for expedited review

Support Resources

Community Health Advocates: Free assistance at 888-614-5400

  • Help filing appeals
  • Document preparation
  • Understanding your rights
  • Searchable database of past decisions

External Review Timeline

  • Standard: 30 days for decision
  • Expedited: 72 hours (24 hours for non-formulary drugs)
  • Binding decision: Aetna must comply if overturned

Counterforce Health helps patients and clinicians navigate complex prior authorization requirements like those for Somatuline Depot. Our platform analyzes denial letters, identifies specific appeal strategies, and drafts evidence-backed responses that address payer criteria point-by-point. By turning insurance denials into targeted appeals with the right clinical evidence and procedural compliance, we help ensure patients get access to necessary specialty medications. Visit www.counterforcehealth.org to learn more about our coverage advocacy services.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Prior authorization requirements and appeal processes may vary by plan and change over time. Always verify current requirements with your insurance provider and consult with your healthcare provider regarding treatment decisions. For personalized assistance with insurance appeals in New York, contact Community Health Advocates at 888-614-5400 or visit the New York State Department of Financial Services.

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