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

How to Get Signifor LAR (Pasireotide) Approved by UnitedHealthcare in Pennsylvania: Complete Prior Authorization and Appeal Guide

Answer Box: Getting Signifor LAR Covered by UnitedHealthcare in Pennsylvania

UnitedHealthcare requires prior authorization for Signifor LAR (pasireotide) through OptumRx specialty pharmacy. Key requirements: endocrinologist prescription, documented Cushing's disease diagnosis with failed/contraindicated surgery, or acromegaly with failed first-generation somatostatin analogs. Submit complete clinical documentation including labs (24-hour UFC for Cushing's, elevated IGF-1 for acromegaly) and surgical history. First step: Call UHC member services using your insurance card number to confirm OptumRx specialty pharmacy contact and obtain the current PA form.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timeline
  6. If You're Asked for More Information
  7. If Your Request is Denied
  8. Appeals Process in Pennsylvania
  9. Renewal and Reauthorization
  10. Cost Assistance Options
  11. Quick Reference Checklist
  12. FAQ

What This Guide Covers

This guide helps patients with Cushing's disease or acromegaly navigate UnitedHealthcare's prior authorization process for Signifor LAR (pasireotide) in Pennsylvania. Whether you're facing an initial denial or preparing your first request, you'll find step-by-step instructions, required forms, and appeal strategies specific to Pennsylvania's strengthened external review program launched in 2024.

Who this helps:

  • Patients prescribed Signifor LAR by an endocrinologist
  • Caregivers managing the approval process
  • Clinic staff submitting prior authorizations
  • Anyone appealing a UnitedHealthcare denial in Pennsylvania

Before You Start: Verify Your Coverage

Step 1: Confirm Your Plan Type

Call UnitedHealthcare member services (number on your insurance card) to verify:

  • Whether you have commercial, Medicare Advantage, or Medicaid coverage
  • If your prescription benefits are managed by OptumRx
  • Your current formulary tier for Signifor LAR (typically Tier 4-5 specialty)

Step 2: Check Network Status

Signifor LAR must be dispensed through an OptumRx specialty pharmacy—not your local retail pharmacy. Verify this requirement hasn't changed by checking your plan documents or calling member services.

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all indications UHC PA Notification
Formulary Tier Specialty (Tier 4-5) Member portal or call UHC
Step Therapy Required for acromegaly only UHC somatostatin analog policy
Prescriber Endocrinologist preferred PA form requirements
Quantity Limit 1 vial per 28 days (LAR) Policy documentation
Appeals Deadline 180 days from denial Member handbook

Gather Required Documentation

Essential Clinical Documentation

For Cushing's Disease:

  • Confirmed endogenous Cushing's disease diagnosis with ICD-10 code
  • Biochemical evidence: At least two abnormal results from:
    • 24-hour urinary free cortisol (UFC)
    • Late-night salivary cortisol
    • Overnight dexamethasone suppression test
  • Surgical history: Documentation that pituitary surgery was not curative or not an option
  • Pituitary MRI results
  • Endocrinologist's clinical assessment

For Acromegaly:

  • Elevated IGF-1 above age-adjusted reference range
  • Failed growth hormone suppression on oral glucose tolerance test
  • Step therapy documentation: Trial and failure/intolerance of first-generation somatostatin analogs (octreotide LAR or lanreotide)
  • Pituitary MRI results
Clinician Corner: Medical Necessity Letter Checklist

Include: (1) Specific diagnosis with ICD-10, (2) Biochemical confirmation with lab values and dates, (3) Prior treatment history and outcomes, (4) Why Signifor LAR is clinically appropriate, (5) Dosing rationale, (6) Monitoring plan for side effects, (7) References to FDA labeling and endocrine society guidelines.

Administrative Documents

  • Current UnitedHealthcare insurance card
  • OptumRx prior authorization form (obtain current version from member services)
  • Prescriber's DEA number and NPI
  • Patient demographics and contact information

Submit Your Prior Authorization Request

Electronic Submission (Required as of December 2024)

UnitedHealthcare now requires all PA submissions through their Provider Portal or API system. Paper and fax submissions are no longer accepted for most requests.

Submission Steps:

  1. Log into the UHC Provider Portal using your clinic's credentials
  2. Navigate to Prior Authorization section
  3. Select "Specialty Pharmacy" for Signifor LAR requests
  4. Complete the PA form with all required clinical information
  5. Upload supporting documents (labs, imaging, clinical notes)
  6. Submit and record confirmation number
Note: If you encounter technical issues with electronic submission, call OptumRx at 1-844-403-1027 for assistance (verify current number with member services).

Clean Request Packet Checklist

  • Completed PA form with all fields filled
  • Prescriber attestation and signature
  • Lab results with reference ranges highlighted
  • Surgical reports or specialist assessment
  • Prior therapy documentation (for acromegaly)
  • Insurance card copy
  • Patient consent forms

Follow-Up and Timeline

Standard Processing Times

  • Routine requests: Up to 15 business days
  • Urgent/expedited: 72 hours (requires clinical justification)
  • Medicare Advantage: May have different timelines per CMS requirements

When to Follow Up

Call OptumRx specialty pharmacy 5 business days after submission if you haven't received a determination. Use this script:

"I'm calling to check the status of a prior authorization for Signifor LAR submitted on [date]. The confirmation number is [number]. Can you provide an update on the review timeline and let me know if any additional information is needed?"

Document: Date, time, representative name, and any reference numbers provided.

If You're Asked for More Information

Common requests include:

  • Additional lab work: Recent glucose monitoring, liver function tests
  • Specialist consultation notes: More detailed endocrinology assessment
  • Treatment timeline: Clearer documentation of prior therapy failures
  • Dosing justification: Explanation of prescribed dose vs. FDA labeling

Response strategy: Provide requested information within the specified timeframe (typically 14 days) and include a cover letter summarizing how the new information supports medical necessity.

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason How to Address
Non-specialist prescriber Obtain endocrinologist prescription or consultation
Insufficient biochemical evidence Submit additional lab results with reference ranges
Missing step therapy (acromegaly) Document octreotide/lanreotide trial and failure
Incomplete surgical history Provide operative reports and post-surgical assessment
Non-formulary status Request formulary exception with medical necessity letter

Peer-to-Peer Review

If denied, request a peer-to-peer review with UnitedHealthcare's medical director. Your endocrinologist can discuss the case directly with a physician reviewer, often leading to approval when clinical documentation is strong.

Appeals Process in Pennsylvania

Pennsylvania's strengthened external review program, launched in January 2024, has shown a 50% overturn rate for appealed denials in its first year.

Internal Appeals (First Step)

  • Deadline: 180 days from denial notice
  • Submission: Through UHC Provider Portal (electronic required)
  • Include: All original documentation plus additional supporting evidence
  • Timeline: UHC has specific timeframes per your plan type

External Review (After Internal Appeal)

Pennsylvania's Independent External Review Program provides a state-supervised appeal process:

  • Eligibility: After receiving Final Adverse Benefit Determination from UHC
  • Deadline: 4 months from final internal denial
  • Submission: Online at pa.gov external review portal or by mail/fax
  • Timeline:
    • Standard review: 45 days
    • Expedited review: 72 hours (for urgent cases)
  • Success rate: Approximately 50% of appeals result in coverage approval
From Our Advocates

We've seen cases where patients initially denied for Signifor LAR successfully obtained coverage through Pennsylvania's external review process by submitting comprehensive biochemical documentation and clear evidence that surgery wasn't curative. The key was organizing all lab results chronologically and including a detailed timeline of treatment attempts. While outcomes vary by individual case, thorough documentation significantly improves appeal success rates.

Getting Help with Appeals

  • Pennsylvania Insurance Department: Consumer Services line for guidance
  • Pennsylvania Health Law Project: Free assistance for complex appeals
  • UnitedHealthcare member services: Plan-specific appeal procedures

Renewal and Reauthorization

Signifor LAR typically requires annual reauthorization. Start the renewal process 30-45 days before your current authorization expires.

Renewal Requirements:

  • Updated endocrinologist assessment
  • Current lab results showing treatment response
  • Documentation of medication adherence (≥85% typically required)
  • Any changes in dosing or administration
  • Continued medical necessity statement

Counterforce Health specializes in helping patients navigate complex prior authorization and appeal processes for specialty medications like Signifor LAR. Their platform can help organize your documentation and create targeted appeals based on your specific denial reasons and UnitedHealthcare's policies.

Cost Assistance Options

Manufacturer Support

  • Recordati Rare Diseases: Patient assistance programs and copay support
  • Eligibility: Income-based and insurance status requirements
  • Contact: Through specialty pharmacy or manufacturer website

Other Resources

  • Pennsylvania CHIP: For qualifying families
  • Medicaid: If eligible, may have different coverage criteria
  • Foundation grants: Various rare disease foundations offer assistance

Quick Reference Checklist

Before Starting:

  • Verify OptumRx specialty pharmacy requirement
  • Confirm endocrinologist is prescriber
  • Gather all lab results and imaging
  • Obtain current PA form

For Submission:

  • Complete electronic PA form
  • Include biochemical documentation
  • Document surgical history/contraindications
  • Attach prior therapy records (acromegaly)
  • Submit through Provider Portal

After Submission:

  • Record confirmation number
  • Follow up in 5 business days
  • Respond promptly to information requests
  • Prepare appeal documentation if denied

FAQ

Q: How long does UnitedHealthcare prior authorization take in Pennsylvania? A: Standard requests take up to 15 business days. Urgent requests with clinical justification are processed within 72 hours.

Q: What if Signifor LAR is non-formulary on my plan? A: Request a formulary exception with comprehensive medical necessity documentation. Include evidence that formulary alternatives are inappropriate or ineffective.

Q: Can I request an expedited appeal if my health is at risk? A: Yes, both UnitedHealthcare and Pennsylvania's external review program offer expedited processes for urgent medical situations.

Q: Does step therapy apply if I tried octreotide in another state? A: Yes, documented trials from other states count toward step therapy requirements. Ensure you have complete records of the trial and outcome.

Q: What's the success rate for appeals in Pennsylvania? A: Pennsylvania's external review program has approximately a 50% overturn rate, significantly higher than many other states.

Q: Who can help me with the appeal process? A: The Pennsylvania Insurance Department, Pennsylvania Health Law Project, and organizations like Counterforce Health offer assistance with complex appeals.

Q: What happens if I pay out-of-pocket during the appeal? A: If your appeal is successful, UnitedHealthcare must provide retroactive coverage, potentially reimbursing you for medications purchased during the appeal period.

Q: Can a non-endocrinologist prescribe Signifor LAR? A: While technically possible, insurance approval is significantly more likely with an endocrinologist prescription or formal consultation documentation.

Disclaimer: This guide provides general information about UnitedHealthcare's prior authorization process and should not be considered medical or legal advice. Coverage policies and procedures may change. Always verify current requirements with UnitedHealthcare and consult with your healthcare provider about treatment decisions.

Need additional help? Contact the Pennsylvania Insurance Department's consumer services line or visit pa.gov for official appeals guidance and forms.

Sources & Further Reading

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