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

How to Get Signifor LAR (Pasireotide) Covered by Humana in Michigan: PA Forms, Appeals Timeline & Cost-Saving Strategies

Quick Answer: Getting Signifor LAR Covered by Humana in Michigan

Signifor LAR (pasireotide) requires prior authorization from Humana for both Cushing's disease and acromegaly treatment. The fastest path to approval involves your endocrinologist submitting comprehensive biochemical documentation—elevated 24-hour urinary free cortisol (UFC) for Cushing's or elevated IGF-1 for acromegaly—along with evidence of failed surgical intervention or first-line therapies. Submit PA requests via fax to 502-508-9300 or call 866-421-5663 (Mon-Fri, 7 a.m.-7 p.m. CT). If denied, Michigan patients have 65 days to appeal internally, then 127 days to file for external review with the Michigan Department of Insurance and Financial Services (DIFS).

First step today: Contact your endocrinologist to gather recent UFC or IGF-1 labs and documentation of prior treatment failures, then have them initiate the PA request through Humana's provider portal.

Table of Contents

  1. Humana Plan Types & Coverage Implications
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Network
  5. Cost-Share Dynamics
  6. Submission Process & Forms
  7. Common Approval Patterns
  8. Appeals Process in Michigan
  9. Patient Assistance Programs
  10. When to Escalate
  11. FAQ

Humana Plan Types & Coverage Implications

Humana offers several plan types in Michigan, each with different coverage rules for Signifor LAR:

Medicare Advantage Plans: Most common for Signifor LAR coverage, with comprehensive specialty drug benefits. Prior authorization applies across all Medicare Advantage plans.

Medicare Part D: Standalone prescription drug plans that cover Signifor LAR as a Tier 5 specialty medication with 33% coinsurance.

Medicaid Plans: Available through Humana's Michigan Medicaid program, with CenterWell Specialty Pharmacy handling complex medications like pasireotide.

Note: Regardless of plan type, Signifor LAR requires prior authorization and specialty pharmacy dispensing through Humana's network.

Formulary Status & Tier Placement

Coverage at a Glance

Requirement Details Where to Verify Source
PA Required Yes, for all indications Humana PA Lists Humana Provider Portal
Formulary Tier Tier 5 (Specialty) Humana Drug Lists Plan-specific formulary
Step Therapy Required through preferred drug PA submission forms Medicare PA List 2025
HCPCS Code J7352 (Signifor LAR) Claims billing Humana billing guide
Specialty Pharmacy CenterWell required Member services 844-486-2668

Alternative medications your plan may prefer first include:

  • Acromegaly: Octreotide LAR, lanreotide, pegvisomant
  • Cushing's disease: Osilodrostat, mifepristone (when surgery isn't feasible)

Prior Authorization Requirements

Medical Necessity Documentation

For Cushing's Disease:

  • Elevated 24-hour urinary free cortisol (UFC) levels
  • MRI confirmation of pituitary adenoma
  • Documentation that surgery failed, is contraindicated, or patient refused
  • ICD-10 diagnosis codes (E24.0 for pituitary-dependent Cushing's)

For Acromegaly:

  • Elevated IGF-1 above age and sex-adjusted normal ranges
  • Failed biochemical control with first-generation somatostatin analogs (octreotide or lanreotide)
  • Evidence of inadequate surgical outcome
  • Growth hormone suppression test results
Clinician Corner: Include specific lab values with reference ranges, dates of prior therapies, and clear documentation of treatment failures or contraindications. The Office of Inspector General reports that comprehensive endocrine labs and specialist prescriber documentation significantly improve approval rates.

Specialty Pharmacy Network

CenterWell Specialty Pharmacy is Humana's designated specialty pharmacy for Signifor LAR. Key details:

  • Phone: 844-486-2668 (TTY: 711)
  • Hours: Monday-Friday 8 a.m.-8 p.m., Saturday 8 a.m.-6 p.m. (Central time)
  • Delivery: Medications shipped to patient's home
  • Setup: Your prescriber will coordinate enrollment after PA approval
Important: Filling Signifor LAR outside the specialty pharmacy network may result in no coverage, leaving patients responsible for the full cost (often exceeding $20,000 per injection).

Cost-Share Dynamics

Tier 5 Specialty Costs

  • Coinsurance: 33% across Humana Medicare Part D plans
  • Coverage Gap: 25% coinsurance after reaching Initial Coverage Limit (~$5,030 in 2025)
  • Out-of-Pocket Maximum: $2,100 annual cap, after which Humana covers 100%

Financial Relief Options

Part D Extra Help: Low-income subsidy reduces specialty coinsurance to approximately $11.20 maximum per month for eligible patients (income <150% Federal Poverty Level). Apply through Social Security Administration.

Submission Process & Forms

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic): Collect recent labs (UFC or IGF-1), prior therapy records, imaging results
  2. Complete PA Form (Prescriber): Access plan-specific forms through Humana Provider Portal
  3. Submit Request (Prescriber): Fax to 502-508-9300 or call 866-421-5663 with complete documentation
  4. Track Status (Clinic): Monitor through provider portal; typical response within 7-14 days
  5. Coordinate Specialty Pharmacy (Patient/Clinic): Once approved, CenterWell will contact patient for enrollment
  6. Schedule Delivery (Patient): Coordinate injection schedule with specialty pharmacy delivery
  7. Monitor Coverage (Patient): Track costs through MyHumana portal

Required Submission Elements

  • National Drug Code (NDC) for specific Signifor LAR strength
  • Complete diagnosis with ICD-10 codes
  • Detailed prior therapy history with dates and outcomes
  • Current lab values with reference ranges
  • Prescriber DEA and NPI numbers

Common Approval Patterns

Successful submissions typically include:

  • Board-certified endocrinologist as prescriber
  • Comprehensive biochemical evidence (not just clinical symptoms)
  • Clear documentation of surgical failure or contraindications
  • Specific dosing rationale based on patient weight/response
  • Treatment goals with measurable outcomes

Common denial reasons and fixes:

Denial Reason How to Address
Insufficient biochemical evidence Submit complete UFC or IGF-1 panels with reference ranges
Step therapy not completed Document trial and failure of preferred alternatives
Non-specialist prescriber Transfer care to board-certified endocrinologist
Dosing outside label Provide literature support or dose reduction rationale

Appeals Process in Michigan

Internal Appeals (Humana)

  • Timeline: 65 days from denial notice to submit appeal
  • Standard review: 7 days for benefit appeals, 14 days for payment appeals
  • Expedited review: 72 hours if health would be seriously harmed by delay
  • Submission: Via Availity Essentials or mail to address on denial notice

External Review (Michigan DIFS)

If Humana's internal appeal is unsuccessful:

  • Timeline: 127 days from final internal denial to request external review
  • Process: Submit External Review Request form to Michigan Department of Insurance and Financial Services
  • Decision timeframe: 60 days standard, 72 hours expedited
  • Contact: DIFS toll-free at 877-999-6442
Michigan Advantage: The state's Patient's Right to Independent Review Act provides robust external review rights, with Independent Review Organizations making binding decisions when insurers inappropriately deny coverage.

Patient Assistance Programs

Manufacturer Support

Recordati Patient Access Program: Contact manufacturer directly for eligibility screening and application assistance. Income-based programs may provide free medication for qualifying patients.

Foundation Assistance

  • Patient Advocate Foundation: Copay relief for patients with insurance coverage
  • HealthWell Foundation: Grants for specialty medication costs
  • National Organization for Rare Disorders (NORD): Financial assistance for rare disease treatments

Humana-Specific Programs

  • CenterWell Pharmacy discounts: Available through specialty pharmacy enrollment
  • Medicare Extra Help: Federal program reducing Part D costs for low-income beneficiaries

Counterforce Health helps patients navigate complex prior authorization requirements and appeal processes for specialty medications like Signifor LAR. Our platform analyzes denial letters and generates evidence-backed appeals tailored to each payer's specific requirements, improving approval rates while reducing administrative burden on patients and providers.

When to Escalate

Contact Michigan DIFS if you experience:

  • Unreasonable delays in PA processing (>30 days)
  • Denial without proper medical review
  • Failure to follow Michigan external review decisions
  • Billing issues after approval

Michigan DIFS Contact: 877-999-6442 or file complaints online at michigan.gov/difs.

FAQ

How long does Humana prior authorization take for Signifor LAR? Standard PA decisions are made within 7-14 days. Expedited requests (when health would be seriously harmed by delay) are decided within 72 hours.

What if Signifor LAR is non-formulary on my plan? Request a formulary exception through your prescriber, providing medical necessity documentation and evidence that formulary alternatives are inappropriate or ineffective.

Can I request an expedited appeal in Michigan? Yes, both Humana internal appeals and Michigan DIFS external reviews offer expedited processing (72 hours) when delays would seriously jeopardize your health.

Does step therapy apply if I've failed therapies outside Michigan? Yes, document all prior therapies regardless of where treatment occurred. Include pharmacy records, prescriber notes, and specific reasons for discontinuation.

What happens if I'm in the Medicare Part D coverage gap? You'll pay 25% coinsurance for Signifor LAR until reaching the $2,100 out-of-pocket maximum, after which Humana covers 100% for the remainder of the year.

How do I find a Humana-participating endocrinologist in Michigan? Use Humana's provider directory or call member services at the number on your insurance card to locate in-network specialists.

Sources & Further Reading

For personalized assistance with Signifor LAR prior authorization and appeals, Counterforce Health provides evidence-based advocacy services that turn insurance denials into targeted, successful appeals.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider regarding treatment decisions and your insurance company for current coverage policies. Coverage policies and appeal procedures may change; verify current requirements through official sources.

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