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

How to Get Signifor LAR (Pasireotide) Covered by Aetna CVS Health in Georgia: Complete Appeals Guide with Forms and Timelines

Answer Box: Getting Signifor LAR Covered by Aetna CVS Health in Georgia

Signifor LAR (pasireotide) requires prior authorization from Aetna CVS Health and is listed as non-preferred. To get coverage in Georgia: (1) Submit PA request through CVS Specialty with complete biochemical evidence (UFC/IGF-1 levels) and documented failure of first-generation somatostatin analogs, (2) If denied, file internal appeal within 180 days, (3) Request Georgia DOI external review within 60 days of final denial. Start with CVS Specialty PA form or call 1-855-240-0535.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Common Denial Reasons & How to Fix Them
  4. Appeals Process for Aetna CVS Health in Georgia
  5. Medical Necessity Documentation
  6. Georgia External Review Process
  7. Scripts and Contact Information
  8. Cost Assistance Programs
  9. FAQ

Coverage Requirements at a Glance

Requirement Details Where to Find It
Prior Authorization Required for both Signifor and Signifor LAR CVS Specialty PA Portal
Formulary Status Non-preferred; Somatuline Depot (lanreotide) is preferred 2025 Aetna Specialty Drug List
Prescriber Requirement Endocrinologist or specialist required Aetna PA criteria
Step Therapy First-generation SSA trial required for acromegaly Aetna medical policy
Lab Documentation UFC, IGF-1, glucose monitoring required FDA labeling requirements
Appeal Deadline (Internal) 180 days from denial notice Aetna member handbook
External Review (Georgia) 60 days from final internal denial Georgia DOI

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation

Who: Your endocrinologist's office
Documents needed:

  • Complete lab panel (UFC, IGF-1, glucose trending over 3-6 months)
  • Documentation of surgical failure/contraindication (Cushing's)
  • First-generation SSA trial records with dates and outcomes (acromegaly)
  • ICD-10 codes (E24.0 for Cushing's, E22.0 for acromegaly)

2. Submit Prior Authorization Request

Who: Prescriber
How: Fax to 1-888-267-3277 or call CVS Specialty at 1-855-240-0535
Timeline: Submit within 5 business days of prescription
Expected decision: 30-45 days standard, 72 hours expedited

3. Request Peer-to-Peer Review (If Initially Denied)

Who: Prescriber
When: Within 24-48 hours of denial
Script: "I'm requesting a peer-to-peer review for [patient name] regarding the Signifor LAR denial. Dr. [Name] has additional clinical information and is available [time blocks]."

4. File Internal Appeal

Who: Patient or prescriber
Deadline: 180 days from denial notice
How: Aetna member portal or written request
Decision timeline: 30 days standard, 72 hours expedited

5. Request Georgia External Review

Who: Patient
Deadline: 60 days from final internal denial
How: Email [email protected] or call 1-800-656-2298
Decision timeline: 30 business days standard, 72 hours expedited

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Insufficient biochemical evidence Submit trending lab data over 3-6 months UFC >ULN, IGF-1 >1.3x age-adjusted normal, failed dexamethasone suppression
No prior SSA trial documented Provide pharmacy records and adverse event notes Exact dates, doses, duration, and documented failure/intolerance of octreotide/lanreotide
Non-specialist prescriber Transfer care or obtain endocrinologist co-signature Endocrinologist evaluation and treatment plan
Alternative therapy available Document specific contraindications Allergy documentation, surgical contraindications, or treatment failure records
Experimental/investigational Cite FDA approval and clinical guidelines FDA labeling for approved indications

Appeals Process for Aetna CVS Health in Georgia

Internal Appeals

  • Standard appeals: 30 calendar days for decision
  • Expedited appeals: 72 hours (for urgent situations)
  • How to file: Aetna member portal, phone (1-855-582-2025), or written request
  • Required documents: Denial letter, medical records, prescriber statement

Georgia External Review

Georgia offers one of the strongest external review processes in the Southeast. After exhausting Aetna's internal appeals:

Eligibility: Medical necessity denials, experimental/investigational denials
Deadline: 60 days from final internal denial notice
Cost: Free to consumers
Process: Georgia DOI assigns independent review organization (IRO)
Decision timeline: 30 business days standard, 72 hours expedited
Contact: Georgia Consumer Services Division at 1-800-656-2298

Note: Georgia's external review decisions are binding on Aetna CVS Health. The state overturned approximately 50% of eligible appeals in recent years.

Medical Necessity Documentation

Clinician Corner: Letter of Medical Necessity Checklist

Your endocrinologist should request Recordati's Letter of Medical Necessity template as the first step. The letter must include:

Essential Elements:

  • Clear ICD-10 diagnosis (E24.0 Cushing's disease, E22.0 acromegaly)
  • Complete biochemical evidence with trending data
  • Detailed prior treatment history with specific outcomes
  • Contraindications to formulary alternatives
  • Dosing rationale and monitoring plan
  • Literature support citing FDA labeling

For Cushing's Disease:

  • Elevated cortisol via 24-hour UFC, late-night salivary cortisol, or dexamethasone suppression test
  • Documentation that pituitary surgery is not curative or not feasible
  • Evidence of disease progression despite standard interventions

For Acromegaly:

  • IGF-1 >1.3× upper normal limit (age/sex-adjusted)
  • GH >1 ng/mL post-oral glucose tolerance test
  • Documented inadequate response to surgery/radiotherapy
  • Trial of first-generation somatostatin analogs with documented failure or intolerance

Counterforce Health helps patients and clinicians navigate complex prior authorization requirements by analyzing denial letters and crafting targeted, evidence-backed appeals that align with payer-specific criteria.

Georgia External Review Process

When to Use External Review

  • Medical necessity denials for FDA-approved indications
  • "Experimental/investigational" denials for established therapies
  • Step therapy denials when alternatives are contraindicated

How to Request

  1. Gather documents: Final internal denial letter, medical records, prescriber statement
  2. Submit request: Email [email protected] or mail to Georgia DOI
  3. Include: Patient information, denial details, supporting clinical evidence
  4. Timeline: Must request within 60 days of final internal denial

What Happens Next

  • Georgia DOI reviews eligibility (usually within 5 business days)
  • Independent review organization assigned randomly
  • Clinical reviewers in same specialty examine case
  • Decision issued within 30 business days (72 hours if expedited)
  • Decision is binding on Aetna CVS Health
From our advocates: "We've seen Georgia external reviews succeed when the clinical documentation clearly shows why Signifor LAR is medically necessary and why alternatives won't work. The key is submitting trending lab data over several months rather than single-point measurements, plus detailed documentation of prior therapy failures with specific dates and outcomes."

Scripts and Contact Information

Patient Script for Aetna CVS Health

"Hi, I'm calling about a prior authorization denial for Signifor LAR. My member ID is [number]. I'd like to understand the specific denial reason and request an internal appeal. Can you connect me with someone who can help with specialty medication appeals?"

Clinic Script for Peer-to-Peer Review

"I'm calling to request a peer-to-peer review for [patient name] regarding the denial for Signifor LAR. Dr. [Name] is available [specific time blocks] and has additional clinical information that wasn't included in the original submission, including trending biochemical data and documented contraindications to preferred alternatives."

Key Contacts

  • CVS Specialty PA: 1-855-240-0535 (WA) / 1-800-323-2445 (NJ)
  • Aetna Prior Authorization: 1-855-582-2025
  • CVS Caremark Fax: 1-888-267-3277
  • Georgia Consumer Services: 1-800-656-2298
  • Georgia DOI External Review: [email protected]

Cost Assistance Programs

Manufacturer Support

  • Recordati Rare Diseases: Patient assistance programs available
  • RARE Resources: Signifor LAR support services
  • Eligibility: Varies by income and insurance status

Foundation Grants

  • Patient Access Network Foundation: Rare disease assistance
  • HealthWell Foundation: Endocrine disorder grants
  • Good Days: Chronic disease support
Tip: Apply for manufacturer copay assistance even while appealing. Many programs provide temporary coverage during the appeals process.

FAQ

How long does Aetna CVS Health prior authorization take in Georgia? Standard PA decisions are made within 30-45 days. Expedited requests (for urgent medical situations) are decided within 72 hours.

What if Signifor LAR is non-formulary on my plan? You can request a formulary exception using the same medical necessity documentation process. Non-formulary exceptions often have higher success rates when clinical evidence is strong.

Can I request an expedited appeal? Yes, if waiting for standard appeal timelines would seriously jeopardize your health or ability to function. Both Aetna and Georgia external review offer expedited processes.

Does step therapy apply if I've tried SSAs outside Georgia? Yes, pharmacy records from any state showing documented trial and failure of first-generation somatostatin analogs should satisfy step therapy requirements.

What happens if my external review is denied? Georgia external review decisions are final for the administrative process. Further disputes would need to proceed through the court system, though this is rare for medically appropriate cases.

How much does Signifor LAR cost without insurance? U.S. discount listings show one 10-20 mg LAR kit often exceeds $20,000 per vial, though actual costs vary by pharmacy and location.

Can my primary care doctor prescribe Signifor LAR? Aetna CVS Health typically requires an endocrinologist or specialist to prescribe Signifor LAR. Non-specialists may need to transfer care or obtain specialist co-signature.

What if I need treatment while my appeal is pending? Request a temporary supply through your prescriber while the appeal is processed. Some plans provide bridge coverage for continuing therapy during appeals.

Disclaimer: This information is for educational purposes and is not medical advice. Always consult your healthcare provider for medical decisions. Coverage policies vary by plan and may change. Verify current requirements with Aetna CVS Health and the Georgia Department of Insurance.

For patients and clinicians navigating complex insurance denials, Counterforce Health provides specialized support in turning insurance denials into successful appeals by analyzing payer-specific criteria and crafting evidence-backed medical necessity arguments.

Sources & Further Reading

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