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

How to Get Signifor LAR (Pasireotide) Covered by Aetna CVS Health in New Jersey: Prior Authorization Guide and Appeals Process

Quick Answer: Getting Signifor LAR Covered by Aetna CVS Health in New Jersey

Signifor LAR (pasireotide) is covered by Aetna CVS Health with prior authorization for FDA-approved indications. For Cushing's disease, you'll need documented elevated cortisol levels (24-hour UFC, late-night salivary cortisol, or dexamethasone suppression test) and evidence that surgery wasn't curative or isn't an option. For acromegaly, step therapy typically requires trying first-generation somatostatin analogs first unless contraindicated.

Your fastest path to approval: Have your endocrinologist submit complete biochemical documentation, clinical notes showing medical necessity, and prior treatment history through CVS Specialty Pharmacy's enrollment process. If denied, New Jersey's Independent Health Care Appeals Program (IHCAP) provides binding external review within 45 days.

First step today: Contact CVS Specialty at 1-800-323-2445 to start the enrollment and prior authorization process.

Table of Contents

  1. Aetna Plan Types and Coverage Implications
  2. Formulary Status and Tier Placement
  3. Prior Authorization Requirements
  4. CVS Specialty Pharmacy Setup Process
  5. Cost-Sharing Basics
  6. Common Denial Reasons and Solutions
  7. New Jersey Appeals Process
  8. Frequently Asked Questions
  9. Sources and Further Reading

Aetna Plan Types and Coverage Implications

Your specific Aetna plan type affects how you access Signifor LAR coverage in New Jersey:

HMO Plans:

  • Require Primary Care Physician (PCP) selection and referrals to endocrinologists
  • Coverage limited to in-network providers only
  • Lower out-of-pocket costs but less flexibility
  • Typical specialist copay: $30

EPO Plans:

  • No PCP or referrals required
  • In-network only coverage (except emergencies)
  • More provider flexibility than HMO
  • Similar specialty drug coverage to HMO plans

PPO Plans:

  • Nationwide provider access
  • Out-of-network benefits available at higher cost
  • No referrals needed for specialists
  • Higher premiums but maximum flexibility
Note: All plan types require prior authorization for Signifor LAR regardless of network status.

Formulary Status and Tier Placement

Signifor LAR appears on Aetna's 2024 specialty formularies but requires prior authorization for all indications. The medication is not on Aetna's exclusion lists, meaning it's a covered benefit when medical necessity criteria are met.

Coverage Details:

  • Formulary Status: Covered specialty medication
  • Prior Authorization: Required for all uses
  • Step Therapy: Applies for acromegaly (first-generation somatostatin analogs preferred)
  • Quantity Limits: Based on FDA-approved dosing
  • Site of Care: Administered at physician office or infusion center

Prior Authorization Requirements

For Cushing's Disease

Initial Authorization Criteria:

  • Documentation of elevated cortisol levels using one of these tests:
    • 24-hour urinary free cortisol (UFC)
    • Late-night salivary cortisol
    • 1 mg overnight dexamethasone suppression test
    • 2 mg/day × 48 hours dexamethasone suppression test
  • Evidence that pituitary surgery is not an option or was not curative
  • Prescribing by an endocrinologist or qualified specialist

Continuation Criteria:

  • Lower cortisol levels compared to baseline
  • Clinical improvement in signs or symptoms
  • Documentation of medication adherence (≥85%)
  • Updated biochemical testing results

For Acromegaly

Step Therapy Requirements:

  • Commercial Plans: Must try octreotide acetate first
  • Medicare Plans: Lanreotide (Somatuline Depot) is preferred
  • Exceptions granted for documented intolerance or contraindications

Medical Necessity Documentation:

  • Elevated IGF-1 levels appropriate for age and gender
  • Inadequate response to surgery or radiotherapy
  • Or patient not a candidate for surgical intervention
Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements by identifying denial reasons and crafting point-by-point rebuttals aligned to each plan's specific rules.

CVS Specialty Pharmacy Setup Process

CVS Specialty Pharmacy handles most Aetna specialty medications, including Signifor LAR. Here's the enrollment process:

Required Documentation

Patient Information:

  • Complete demographics and contact preferences
  • Insurance card and member ID
  • Parent/guardian details if applicable

Prescriber Requirements:

  • CVS Specialty enrollment form (acromegaly or Cushing's disease specific)
  • Full prescriber details: NPI, state license, DEA number
  • Handwritten signature (stamps not accepted for DAW prescriptions)

Clinical Documentation:

  • Recent lab values (UFC, salivary cortisol, IGF-1 as appropriate)
  • Chart notes demonstrating medical necessity
  • Prior treatment history and outcomes
  • Diagnosis codes (ICD-10)

Submission Process

  1. Complete enrollment form specific to your condition
  2. Submit via fax to 1-800-323-2445 or through electronic prescription
  3. Include all clinical documentation to avoid delays
  4. Specify administration site (office, infusion center, home health)
  5. Request patient support programs if desired

Timeline: Start the process 30-45 days before needed therapy to allow for prior authorization review and potential appeals.

Cost-Sharing Basics

Specialty medications like Signifor LAR typically fall into the highest cost-sharing tier. Your out-of-pocket costs depend on your specific plan:

Typical Cost Structure:

  • Specialty Tier Copay: $25-$50 for 30-day supply (varies by plan)
  • Coinsurance: 40% after deductible for non-preferred brands
  • Maximum Out-of-Pocket: Annual limit applies to protect from excessive costs

Financial Assistance Options:

  • Recordati's R.A.R.E.® Patient Support Program
  • State pharmaceutical assistance programs
  • Foundation grants for rare disease treatments
  • Copay assistance cards (eligibility varies)

Common Denial Reasons and Solutions

Denial Reason Required Documentation How to Submit
Lack of biochemical evidence 24-hour UFC, salivary cortisol, or DST results Include lab reports with PA request
Step therapy not met Document intolerance/failure of first-line agents Medical records showing adverse effects
Non-specialist prescriber Transfer care to endocrinologist Update prescriber information
Experimental/investigational FDA approval documentation Include FDA labeling and indication
Quantity exceeds limits Clinical rationale for dosing Prescriber letter explaining dose selection
From our advocates: "We've seen denials overturned when providers include a detailed timeline showing how the patient progressed through standard treatments before needing Signifor LAR. The key is connecting each prior therapy attempt to specific clinical outcomes and lab values."

New Jersey Appeals Process

New Jersey provides robust appeal rights through the Independent Health Care Appeals Program (IHCAP).

Internal Appeals (Aetna)

First Level:

  • Submit within 180 days of denial
  • Include medical records supporting necessity
  • Aetna has 30 days for standard review (72 hours for urgent)

Second Level:

  • Required for HMO/PPO plans before external review
  • Additional clinical documentation may be requested
  • Peer-to-peer review available with prescribing physician

External Review (IHCAP)

Eligibility:

  • Complete Aetna's internal appeal process
  • Submit within 4 months (180 days) of final denial
  • Denial must be based on medical necessity

Process:

  • Submit directly to Maximus Federal Services (contracted IURO)
  • Preliminary review within 5 business days
  • Full physician panel review within 45 days
  • Decision is binding on Aetna

Contact Information:

  • IHCAP Hotline: 1-888-393-1062
  • NJ DOBI Consumer Hotline: 1-800-446-7467
Tip: About half of external appeals nationwide favor consumers, making New Jersey's IHCAP a valuable option when internal appeals fail.

For assistance navigating complex appeals, Counterforce Health provides expert support in crafting evidence-backed appeals that address specific payer requirements and denial reasons.

Frequently Asked Questions

Q: How long does Aetna prior authorization take for Signifor LAR? A: Standard PA decisions typically take 30-45 days. Expedited reviews for urgent cases are completed within 72 hours.

Q: What if Signifor LAR is non-formulary on my plan? A: You can request a formulary exception with documentation showing medical necessity and failure of preferred alternatives.

Q: Can I get expedited appeal review in New Jersey? A: Yes, if delay would cause serious harm to your health. Both Aetna and IHCAP offer expedited processes.

Q: Does step therapy apply if I failed treatments outside New Jersey? A: Yes, documented treatment failures from any location count toward step therapy requirements.

Q: What happens if CVS Specialty isn't in my network? A: Most Aetna plans designate CVS Specialty as the preferred specialty pharmacy. Check with member services for alternatives.

Q: How do I prove surgery wasn't curative for Cushing's disease? A: Provide post-surgical cortisol levels showing persistent elevation and clinical documentation of ongoing symptoms.

Q: Can my doctor request peer-to-peer review? A: Yes, prescribers can request direct discussion with Aetna's medical directors during the appeal process.

Q: What if I need Signifor LAR for an off-label use? A: Off-label coverage requires additional documentation from recognized drug compendia showing evidence of efficacy.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance. For official appeals procedures and forms, contact Aetna member services or the New Jersey Department of Banking and Insurance.

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