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

How to Get Signifor LAR (Pasireotide) Covered by Aetna CVS Health in Ohio: Complete Prior Authorization Guide with Appeals Timeline

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

Signifor LAR (pasireotide) requires prior authorization from Aetna CVS Health and is non-preferred on their formulary. To get coverage in Ohio: (1) Submit complete PA documentation showing elevated cortisol/IGF-1 levels, surgical failure/contraindication, and specialist prescriber, (2) If denied, file internal appeal within 180 days citing Ohio's step therapy protections if applicable, (3) Request external review through Ohio Department of Insurance within 180 days of final denial. Start today: Contact CVS Specialty at 1-855-240-0535 to begin PA process.

Table of Contents

  1. Why Ohio State Rules Matter
  2. Aetna CVS Health Coverage Requirements
  3. Step-by-Step: Fastest Path to Approval
  4. Ohio's Step Therapy Protections
  5. Appeals Process and Ohio External Review
  6. Common Denial Reasons & How to Fix Them
  7. Scripts for Patients and Providers
  8. Cost-Saving Resources
  9. FAQ

Why Ohio State Rules Matter

Ohio's insurance regulations provide crucial protections that can help overturn Aetna CVS Health denials for Signifor LAR (pasireotide). Unlike many states, Ohio has robust step therapy override requirements and consumer-friendly external review processes that apply to state-regulated plans.

Key Ohio advantages:

  • 180-day appeal window (longer than many states)
  • Automatic approval if insurers don't respond to step therapy exemption requests within 10 days
  • Independent medical review through accredited organizations
  • Binding external review decisions that insurers must honor

These protections interact with Aetna's policies to create multiple pathways for coverage, especially when you can demonstrate medical necessity and prior treatment failures.

Note: Self-funded employer plans (ERISA) may not be subject to Ohio state protections, but many voluntarily follow similar processes.

Aetna CVS Health Coverage Requirements

Requirement Details Ohio-Specific Notes
Formulary Status Non-preferred (higher copay) Subject to Ohio external review if denied
Prior Authorization Required for both Signifor and Signifor LAR Must respond within Ohio timelines
Prescriber Endocrinologist preferred Non-specialist denials can be appealed
Step Therapy First-generation SSA required for acromegaly Ohio override protections apply
Quantity Limit 60 ampules per 30 days (subcutaneous) Can request exception with documentation

Medical Necessity Criteria

For Cushing's Disease:

  • Elevated 24-hour urinary free cortisol, late-night salivary cortisol, or dexamethasone suppression test
  • Non-curative pituitary surgery or patient not a surgical candidate
  • Documentation of disease progression

For Acromegaly:

  • IGF-1 levels >1.3× upper normal limit for age/sex
  • Growth hormone >1 ng/mL post-oral glucose tolerance test
  • Documented failure/intolerance of octreotide LAR or lanreotide
  • Inadequate response to surgery or radiotherapy

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation

Who: Patient and clinic staff
Timeline: 1-2 business days

  • Insurance card and policy details
  • Complete lab panel (UFC, IGF-1, glucose trends over 3-6 months)
  • Surgical records or contraindication documentation
  • Prior therapy records with specific dates and outcomes

2. Contact CVS Specialty for PA Initiation

Who: Prescriber or authorized staff
Contact: 1-855-240-0535
Fax: 1-888-267-3277
Timeline: Same day

  • Request Signifor LAR PA form
  • Verify current formulary status
  • Confirm required documentation

3. Submit Complete PA Request

Who: Prescriber
Timeline: 3-5 business days for processing
Include:

  • Completed Aetna Signifor LAR precertification form
  • Clinical notes with diagnosis (ICD-10: E24.0 for Cushing's, E22.0 for acromegaly)
  • Lab results showing biochemical evidence
  • Documentation of surgical failure or contraindication

4. Monitor Decision Timeline

Standard PA Response: 30 days
Expedited (if urgent): 72 hours with physician certification

  • Track submission with fax confirmation
  • Follow up if no response within 15 days

5. If Denied: Immediate Appeal Strategy

Timeline: File within 180 days of denial notice

  • Request peer-to-peer review immediately
  • Cite Ohio step therapy protections if applicable
  • Gather additional supporting evidence

Ohio's Step Therapy Protections

Ohio Revised Code sections 3901.831 and 3901.832 provide powerful tools for overturning step therapy requirements. Aetna must grant an exemption if any of these conditions are met:

Automatic Exemption Criteria

  1. Contraindication: Signifor LAR is contraindicated per FDA prescribing information
  2. Prior Failure: Patient previously tried and failed first-generation somatostatin analogs
  3. Current Stability: Patient is stable on Signifor LAR from previous coverage

Documentation Requirements

Include specific language in your exemption request:

  • "Patient experienced [specific adverse effect] with octreotide LAR on [dates]"
  • "Discontinuation was medically necessary due to [documented reason]"
  • "Patient meets Ohio Revised Code 3901.832 exemption criteria"

Ohio Timeline Advantage

Aetna must respond within:

  • 48 hours for urgent requests
  • 10 calendar days for standard requests
  • Automatic approval if no response within timeframe

Counterforce Health helps patients and providers navigate these complex step therapy requirements by drafting targeted appeals that cite specific Ohio protections and payer policies.

Appeals Process and Ohio External Review

Internal Appeals with Aetna CVS Health

Level 1 Appeal Timeline:

  • Filing deadline: 180 days from denial notice
  • Response time: 30 days standard, 72 hours expedited
  • Required: Medical necessity letter, clinical records, peer-reviewed citations

Level 2 Appeal (if needed):

  • Filing deadline: 60 days from Level 1 denial
  • Response time: 30 days
  • Enhanced review: Different medical reviewers

Ohio External Review Process

When internal appeals are exhausted, Ohio's external review provides an independent medical assessment:

Eligibility:

  • Final adverse determination from Aetna
  • Involves medical judgment or necessity
  • Request filed within 180 days

Process:

  1. Submit request to Aetna (they forward to Ohio DOI)
  2. Independent Review Organization (IRO) assigned randomly
  3. Submit additional evidence within 10 business days
  4. Decision timeline: 30 days standard, 72 hours expedited

Ohio Department of Insurance Contact:

Common Denial Reasons & How to Fix Them

Denial Reason Solution Strategy Required Documentation
"Not medically necessary" Submit comprehensive clinical rationale with peer-reviewed citations Updated labs, treatment history, specialist notes
"Step therapy not completed" File Ohio step therapy exemption citing prior failure/contraindication Specific dates, adverse events, medical records
"Non-formulary drug" Request formulary exception with medical necessity justification Comparative effectiveness data, cost analysis
"Experimental/investigational" Cite FDA approval and established guidelines FDA label, endocrine society recommendations
"Non-specialist prescriber" Transfer to endocrinologist or request exception Specialist consultation, referral documentation

Scripts for Patients and Providers

Patient Phone Script for Aetna CVS Health

"Hello, I'm calling about a prior authorization denial for Signifor LAR. My policy number is [X]. I'd like to request an expedited peer-to-peer review with the medical director. My doctor says this medication is urgent for my Cushing's disease/acromegaly, and I meet Ohio's step therapy exemption criteria because I failed octreotide LAR. Can you connect me with the appeals department and provide the direct fax number for my doctor's office?"

Provider Peer-to-Peer Request Script

"I'm requesting immediate peer-to-peer review for [patient name], policy [X], for Signifor LAR denial. This patient has biochemically confirmed [Cushing's disease/acromegaly] with [specific lab values]. They failed/were intolerant to [prior therapy] due to [specific reason]. Under Ohio Revised Code 3901.832, this qualifies for step therapy exemption. The medication is medically necessary to prevent [specific complications]. When can we schedule the peer-to-peer review?"

Cost-Saving Resources

Manufacturer Support

  • Recordati Patient Assistance: Contact 1-888-575-8344
  • Copay assistance programs: May reduce out-of-pocket costs
  • Free drug programs: For qualifying uninsured patients

Ohio-Specific Resources

  • Ohio Department of Insurance: Consumer assistance for coverage disputes
  • UHCAN Ohio: Nonprofit advocacy for health coverage issues
  • Legal Aid: For complex ERISA plan appeals
From our advocates: "We've seen patients successfully get Signifor LAR covered after initial denials by combining Ohio's step therapy protections with detailed medical necessity documentation. The key is demonstrating specific prior treatment failures with dates and documented adverse effects. Don't give up after the first denial—Ohio's external review process has helped many patients access this critical medication."

FAQ

Q: How long does Aetna CVS Health prior authorization take in Ohio?
A: Standard PA decisions take up to 30 days. Expedited reviews (with physician urgency certification) must be completed within 72 hours under Ohio regulations.

Q: What if Signifor LAR is non-formulary on my plan?
A: You can request a formulary exception by demonstrating medical necessity and providing comparative effectiveness data showing why preferred alternatives aren't appropriate.

Q: Can I request an expedited appeal in Ohio?
A: Yes, if your physician certifies that delays could seriously jeopardize your health. Ohio requires 72-hour response times for expedited reviews.

Q: Does Ohio's step therapy protection apply if I failed medications outside Ohio?
A: Yes, Ohio's protections apply to prior failures regardless of where they occurred, as long as you can document the failure or intolerance with medical records.

Q: What happens if Ohio external review upholds the denial?
A: External review decisions are binding, but you may still pursue other options like regulatory complaints or legal action. New medical evidence might support a fresh appeal.

Q: How does Counterforce Health help with Signifor LAR appeals?
A: Counterforce Health analyzes denial letters and drafts evidence-backed appeals that align with Aetna's specific policies and Ohio's regulatory protections, increasing approval chances.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and plan terms. Always consult with your healthcare provider and insurance company for specific guidance. For personalized assistance with complex appeals, consider consulting with specialized advocacy services like Counterforce Health.

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