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

How to Get Signifor LAR (Pasireotide) Covered by Blue Cross Blue Shield in Georgia: Timeline, Forms & Appeals Guide

Answer Box: Getting Signifor LAR Covered by BCBS Georgia

Blue Cross Blue Shield Georgia typically processes Signifor LAR (pasireotide) prior authorization requests within 1-14 days, depending on complexity. For Cushing's disease or acromegaly patients, the fastest path involves: (1) gathering complete lab results (UFC, IGF-1) and prior treatment records, (2) having your endocrinologist submit through the Anthem provider portal with medical necessity documentation, and (3) requesting expedited review if clinically urgent. If denied, you have up to 4 months to file an external review with the Georgia Department of Insurance.

Table of Contents

  1. What Affects Signifor LAR 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 & Outcomes
  6. If Denied: Appeal Process
  7. Renewal Cycles & Reauthorization
  8. Timeline Overview Table
  9. Common Denial Reasons & Solutions
  10. Appeals Playbook for Georgia
  11. Frequently Asked Questions

What Affects Signifor LAR Approval Timing

Several factors influence how quickly BCBS Georgia processes your Signifor LAR (pasireotide) prior authorization:

Benefit Type & Complexity

  • Medical benefit drugs like Signifor LAR typically require more clinical documentation than standard pharmacy medications
  • Specialty medications often undergo additional review layers, extending timelines to 5-14 business days
  • Rare disease treatments may require specialist review, adding 3-7 days

Documentation Completeness Your submission speed depends heavily on having complete records upfront. Missing elements that commonly delay approval include:

  • Biochemical confirmation (urinary free cortisol for Cushing's, IGF-1 levels for acromegaly)
  • Documentation of failed first-line treatments (octreotide LAR, lanreotide for acromegaly)
  • Specialist prescriber credentials (endocrinologist preferred)

Plan-Specific Requirements BCBS Georgia (operating as Anthem) has specific criteria that must be met before approval. According to BCBS policy documents, Signifor LAR requires evidence of continued clinical benefit for renewals and specific dosing documentation.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Before submitting your prior authorization request, gather these critical documents:

✓ Lab Results (within 3 months):

  • For Cushing's disease: 24-hour urinary free cortisol (UFC) levels
  • For acromegaly: IGF-1 levels, growth hormone suppression test results

✓ Prior Treatment Records:

  • Documentation of surgical outcomes (if pituitary surgery attempted)
  • Records of failed or contraindicated first-generation somatostatin analogs (octreotide LAR, lanreotide) for acromegaly patients
  • Any adverse reactions to alternative treatments

✓ Clinical Notes from your endocrinologist including:

  • Current symptoms and functional status
  • Treatment goals and expected outcomes
  • Dosing rationale (10-40 mg every 4 weeks)

✓ Insurance Information:

  • Current BCBS Georgia member ID
  • Policy effective dates
  • Confirmation of medical benefit coverage
Tip: Submit requests electronically through the provider portal when possible. Electronic submissions typically process 1-3 days faster than fax submissions.

Submission to Initial Review (1-5 Days)

How BCBS Georgia Processes Requests

Once your provider submits the prior authorization through the Anthem provider portal, the review process begins:

Day 1-2: Administrative Review

  • Verification of member eligibility and benefits
  • Confirmation that all required fields are completed
  • Assignment to clinical review team

Day 2-5: Clinical Review BCBS clinical pharmacists and medical directors review your case against specific criteria:

  • FDA-approved indications (Cushing's disease when surgery not curative; acromegaly inadequately controlled)
  • Medical necessity documentation
  • Appropriate prescriber (endocrinologist preferred)
  • Dosing within FDA guidelines

Electronic vs. Fax Timelines According to current BCBS Georgia processing standards:

  • Electronic submission: 1-3 business days
  • Fax submission: 3-5 business days
  • Complex cases: Up to 14 business days

Additional Information Requests (1-7 Days)

If BCBS needs more information, they'll contact your provider directly. Common requests include:

Missing Clinical Data

  • More recent lab results
  • Detailed surgical history
  • Documentation of contraindications to alternatives

Clarification Requests

  • Specific dosing rationale
  • Expected duration of treatment
  • Monitoring plan for side effects (hyperglycemia, gallbladder issues)

How to Respond Quickly

  • Providers should respond within 24-48 hours to avoid delays
  • Submit additional documentation through the same portal used for the original request
  • Include the original prior authorization reference number

Decision Window & Outcomes

Typical Decision Timeline

  • Standard requests: 72 hours after complete documentation received
  • Expedited requests: 24 hours for urgent cases
  • Complex specialty cases: Up to 14 calendar days

Reading Your Approval Letter Approved requests will specify:

  • Approved dosing and frequency
  • Duration of authorization (typically 12 months)
  • Required specialty pharmacy (if applicable)
  • Any quantity limits

Partial Approvals Sometimes BCBS approves a lower dose or shorter duration than requested. This allows treatment to begin while additional data is collected.

If Denied: Appeal Process

Understanding Your Denial Letter Common denial reasons for Signifor LAR include:

  • Insufficient documentation of medical necessity
  • Lack of evidence of failed first-line treatments
  • Missing specialist evaluation
  • Dosing outside FDA parameters

Internal Appeal (First Level) You have 60 days from the denial date to file an internal appeal with BCBS Georgia. Include:

  • Original denial letter
  • Additional clinical documentation
  • Provider letter explaining medical necessity
  • Any new lab results or imaging

Timeline for Internal Appeals

  • Standard internal appeal: 30 days for decision
  • Expedited internal appeal: 72 hours if urgent

If your internal appeal is denied, you can proceed to external review through the Georgia Department of Insurance.

Renewal Cycles & Reauthorization

Annual Reauthorization Required Signifor LAR typically requires reauthorization every 12 months. According to BCBS renewal criteria, you'll need to demonstrate:

For Acromegaly Patients:

  • Improved or maintained IGF-1 levels
  • Evidence of clinical benefit (symptom improvement, tumor size reduction)
  • Continued medical necessity

For Cushing's Disease Patients:

  • Decreased urinary free cortisol levels
  • Clinical improvement in Cushing's symptoms
  • Ongoing need when surgery isn't curative

Renewal Timeline Submit reauthorization requests 30-60 days before your current approval expires to avoid treatment gaps.

Timeline Overview Table

Phase Standard Timeline Expedited Timeline Key Actions
Pre-submission prep 0-2 days Same Gather labs, records, clinical notes
Initial submission 1-3 days (electronic) Same Submit via provider portal
Clinical review 2-5 days 24 hours BCBS reviews medical necessity
Additional info requests 1-7 days 1-2 days Respond quickly with missing data
Final decision Up to 14 days total 24-72 hours Receive approval/denial letter
Internal appeal 30 days 72 hours File if denied
External review 30 days 72 hours Georgia DOI process

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
"Not medically necessary" Provide detailed clinical rationale Specialist letter, lab results, symptom documentation
"Step therapy not completed" Document failed alternatives Records of octreotide/lanreotide trials and outcomes
"Dosing outside parameters" Justify dose with clinical data Weight-based calculations, prior dose responses
"Non-specialist prescriber" Transfer to endocrinologist Referral and specialist evaluation
"Insufficient lab data" Submit recent biochemical tests UFC, IGF-1, growth hormone levels

Appeals Playbook for Georgia

Level 1: Internal Appeal with BCBS

  • Deadline: 60 days from denial date
  • How to file: Through provider portal or written request
  • Timeline: 30 days for standard, 72 hours for expedited
  • Required: Original denial, new clinical evidence, provider support letter

Level 2: External Review with Georgia DOI If your internal appeal is denied, you can request an independent external review:

  • Deadline: 4 months from final internal denial
  • How to file: Submit request to Georgia Department of Insurance
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Cost: Free for consumers
  • Binding: Yes, the decision is binding on BCBS

Contact Information:

From our advocates: We've seen cases where patients initially denied for Signifor LAR were approved on appeal after their endocrinologist provided more detailed documentation of failed octreotide trials and current symptom burden. The key was demonstrating that standard treatments were inadequate and that pasireotide offered unique benefits through its SSTR5 receptor affinity. While outcomes vary, thorough documentation significantly improves appeal success rates.

Frequently Asked Questions

How long does BCBS Georgia take for Signifor LAR prior authorization? Standard requests take 1-14 days depending on complexity. Electronic submissions through the provider portal are typically processed within 3-5 days, while complex cases requiring additional review may take up to 14 days.

What if Signifor LAR is not on BCBS Georgia's formulary? You can request a formulary exception by demonstrating medical necessity and providing documentation that covered alternatives are ineffective or contraindicated. Include detailed clinical rationale and supporting lab data.

Can I request expedited review for urgent cases? Yes, if delay would seriously jeopardize your health, your provider can request expedited review. Mark submissions as "urgent" and provide clinical justification for the urgency.

Does step therapy apply if I've tried treatments outside Georgia? Yes, BCBS Georgia will typically accept documentation of failed therapies from other states or providers, as long as you have complete medical records showing the trials and outcomes.

What happens if my appeal is denied by BCBS? You can request external review through the Georgia Department of Insurance within 4 months of the final internal denial. This independent review is free and binding on the insurer.

How much does Signifor LAR cost without insurance? Signifor LAR can cost over $20,000 per monthly injection. However, the manufacturer Recordati offers patient assistance programs, and various foundations provide grants for eligible patients.

Getting Additional Support

If you're struggling with the approval process, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to identify the specific reasons for denial, then drafts point-by-point rebuttals aligned with your plan's own rules and pulls relevant clinical evidence to support your case.

For additional consumer assistance in Georgia:

  • Georgians for a Healthy Future: Provides consumer guides and one-on-one help
  • Georgia Legal Services Program: Assists with Medicaid/PeachCare appeals
  • BCBS Georgia Customer Service: Available on your member ID card

Sources & Further Reading

This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific guidance regarding your coverage and treatment options. For official appeals processes and deadlines, refer to your BCBS Georgia policy documents and the Georgia Department of Insurance website.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.