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

How to Get Signifor LAR (Pasireotide) Covered by Humana in Virginia: Appeals, Forms, and Cost-Saving Strategies

Quick Answer: Getting Signifor LAR Covered by Humana in Virginia

Signifor LAR requires prior authorization from Humana and is placed in Tier 5 (specialty tier). Your fastest path to approval: 1) Have your endocrinologist submit a prior authorization with complete biochemical evidence (elevated UFC for Cushing's or IGF-1 for acromegaly), 2) Include documentation of surgical failure/ineligibility, and 3) Submit via Humana's provider portal or fax to 1-888-447-3430. If denied, you have 65 days to appeal internally, then 120 days for Virginia's external review process. Commercial insurance patients may qualify for Recordati's $20 copay card through their R.A.R.E. Patient Support Program.

Table of Contents

  1. What Drives Signifor LAR Costs with Humana
  2. Understanding Your Benefits: Key Information to Gather
  3. Manufacturer Assistance and Cost-Saving Options
  4. Prior Authorization Requirements and Process
  5. Appeals Process: Internal and Virginia External Review
  6. Specialty Pharmacy Coordination
  7. Annual Renewal and Budget Planning
  8. Scripts and Templates for Success
  9. Common Denial Reasons and How to Fix Them
  10. FAQ: Signifor LAR Coverage in Virginia

What Drives Signifor LAR Costs with Humana

Signifor LAR (pasireotide) carries a significant price tag—often exceeding $20,000 per monthly vial—making it one of the most expensive specialty medications. Humana classifies Signifor LAR as a Tier 5 specialty drug, which typically means:

  • Higher copays or coinsurance (often 25-50% of drug cost)
  • Mandatory prior authorization before any coverage
  • Specialty pharmacy dispensing requirements
  • Possible step therapy (trying other treatments first)

Your out-of-pocket costs depend on several factors:

  • Plan type: Medicare Advantage vs. commercial coverage
  • Deductible status: Whether you've met your annual deductible
  • Coverage phase: Medicare Part D "donut hole" considerations
  • Site of care: Whether administered in-office or at home
Tip: Request a benefits investigation from your clinic's prior authorization team before starting treatment. They can predict your exact costs and identify assistance options.

Understanding Your Benefits: Key Information to Gather

Before pursuing coverage, collect these essential details:

Insurance Information Checklist

  • Member ID and group number from your insurance card
  • Plan type (Medicare Advantage, commercial, etc.)
  • Pharmacy benefit manager (often CenterWell for Humana)
  • Current deductible and out-of-pocket maximum
  • Specialty tier copay/coinsurance percentage

Questions to Ask Humana Member Services

Call the number on your insurance card and ask:

  1. "Is Signifor LAR covered on my formulary, and what tier is it?"
  2. "What's my copay or coinsurance for Tier 5 specialty drugs?"
  3. "Does Signifor LAR require prior authorization?"
  4. "Are there step therapy requirements I need to meet first?"
  5. "Which specialty pharmacies are in-network for this medication?"

Document the representative's name, date, and reference number for your records.

Manufacturer Assistance and Cost-Saving Options

Recordati's R.A.R.E. Patient Support Program

Commercially insured patients may qualify for a $20 copay card through Recordati Rare Diseases. Key details:

Eligibility Requirements:

  • Must have commercial (private) insurance coverage
  • Government insurance (Medicare, Medicaid, TRICARE, VA) patients are not eligible
  • Enrollment in R.A.R.E. Patient Support Program required

How to Apply:

  1. Call 1-888-855-RARE (7273), Monday-Friday
  2. Complete Patient Prescription Form
  3. Submit to specialty pharmacy (Anovo Specialty Rx)
  4. Await eligibility determination

Additional Financial Resources

For patients who don't qualify for the copay card:

  • Patient Assistance Programs: Recordati offers free drug programs for uninsured/underinsured patients
  • Charitable foundations: Organizations like Patient Advocate Foundation may provide grants
  • State programs: Virginia residents may qualify for additional assistance through local programs

Counterforce Health helps patients navigate these complex assistance programs and can identify the best combination of resources for your specific situation.

Prior Authorization Requirements and Process

Required Documentation for Approval

Your endocrinologist must submit comprehensive documentation to Humana, including:

Requirement Details Source Required
Diagnosis Cushing's disease (E24.0) or Acromegaly (E22.0) ICD-10 coding, clinical notes
Biochemical Evidence UFC ≥2x normal (Cushing's) or elevated IGF-1 (acromegaly) Lab reports with dates
Surgical History Documentation of failed/inappropriate surgery Operative notes, imaging
Prescriber Specialty Board-certified endocrinologist preferred Provider credentials
Treatment Goals Specific therapeutic targets Clinical rationale

Step-by-Step Prior Authorization Process

  1. Gather Documentation (1-2 days)
    • Your clinic collects all required clinical evidence
    • Lab results, imaging, and surgical reports compiled
  2. Submit PA Request (Same day)
  3. Humana Review (Up to 14 days)
    • Clinical reviewers evaluate against coverage criteria
    • May request additional information or peer-to-peer review
  4. Decision Notification (1-2 days)
    • Approval: Prescription forwarded to specialty pharmacy
    • Denial: Written explanation with appeal rights provided
Clinician Corner: Include a detailed letter of medical necessity addressing why surgery wasn't curative, current biochemical status, and treatment goals. Reference FDA labeling and endocrine society guidelines to strengthen your case.

Appeals Process: Internal and Virginia External Review

Humana Internal Appeals

If your initial prior authorization is denied:

Timeline: 65 days from denial notice to file appeal How to Submit:

  • Online through Humana member portal
  • Fax: 1-888-447-3430
  • Mail: Address on denial letter

Required Documents:

  • Copy of denial letter
  • New clinical evidence (if available)
  • Letter of medical necessity from prescriber
  • Patient statement (optional but helpful)

Virginia External Review Process

After exhausting Humana's internal appeals, Virginia residents can request an independent external review through the State Corporation Commission Bureau of Insurance.

Key Details:

  • Deadline: 120 days from Humana's final denial
  • Forms: Use SCC Form 216-A (standard) or 216-C (expedited)
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Cost: Free to patients
  • Decision: Binding on Humana

Submit by:

  • Fax: 804-371-9915
  • Email: [email protected]
  • Mail: SCC Bureau of Insurance, P.O. Box 1157, Richmond, VA 23218
Note: Virginia's external review process has a strong track record for overturning wrongful denials, especially for rare disease treatments with clear medical necessity.

Specialty Pharmacy Coordination

Signifor LAR must be dispensed through Humana's specialty pharmacy network, typically CenterWell Specialty Pharmacy.

What to Expect:

  • Intake call within 24-48 hours of approval
  • Benefits verification and cost estimate
  • Delivery coordination (usually 2-3 business days)
  • Injection training if self-administered
  • Refill reminders and adherence support

Important Coordination Tips:

  • Provide accurate contact information and preferred delivery address
  • Confirm refrigeration requirements with pharmacy
  • Schedule delivery to avoid weekends/holidays
  • Keep specialty pharmacy contact information readily available

Annual Renewal and Budget Planning

What Changes Annually:

  • Formulary status: Drugs can move tiers or be removed
  • Prior authorization criteria: Requirements may become stricter
  • Copay/coinsurance amounts: Usually increase year-over-year
  • Deductible reset: Out-of-pocket costs restart in January

Renewal Planning Strategy:

  1. Review plan changes in October-November
  2. Resubmit prior authorization if required by new plan year
  3. Budget for deductible restart if applicable
  4. Renew manufacturer assistance programs annually

Counterforce Health tracks these changes and can help ensure continuous coverage across plan years.

Scripts and Templates for Success

Patient Script for Calling Humana

"Hi, I'm calling about prior authorization for Signifor LAR. My member ID is [X]. I have [Cushing's disease/acromegaly] and my endocrinologist submitted a PA request on [date]. Can you tell me the status and what additional information might be needed?"

Follow-up questions:

  • "What specific criteria wasn't met?"
  • "Can we schedule a peer-to-peer review with my doctor?"
  • "What's the timeline for a decision?"

Medical Necessity Letter Template

[Date]
Humana Prior Authorization Department
Re: [Patient Name], DOB: [Date], Member ID: [Number]
Diagnosis: Cushing's disease/Acromegaly

I am requesting coverage for Signifor LAR (pasireotide) for my patient with [diagnosis] based on the following medical necessity:

1. DIAGNOSIS: Confirmed [condition] with biochemical evidence:
   - [Specific lab values and dates]
   - [Imaging findings if relevant]

2. SURGICAL HISTORY: 
   - [Details of surgical failure/ineligibility]
   - [Contraindications to surgery]

3. TREATMENT RATIONALE:
   - FDA-approved indication met
   - No suitable alternatives based on [specific reasons]
   - Expected clinical benefit: [specific goals]

Attached documentation supports medical necessity per Humana's coverage criteria.

Sincerely,
[Provider Name, Credentials]

Common Denial Reasons and How to Fix Them

Denial Reason Fix Strategy Required Documentation
Insufficient biochemical evidence Submit complete lab workup UFC results, IGF-1 levels, confirmatory tests
Surgery not attempted/failed Document surgical history Operative notes, imaging, specialist consultation
Non-specialist prescriber Transfer care or get consultation Endocrinologist referral/co-management
Step therapy not completed Request medical exception Letter explaining why alternatives inappropriate
Dosing outside FDA label Provide clinical justification Literature support, treatment guidelines

FAQ: Signifor LAR Coverage in Virginia

How long does Humana prior authorization take in Virginia? Standard timeline is up to 14 days. Expedited requests (with clinical urgency) are processed within 72 hours.

What if Signifor LAR is non-formulary on my plan? You can request a formulary exception with medical necessity documentation. Virginia external review is available if denied.

Can I request an expedited appeal? Yes, if your physician certifies that delay could jeopardize your health. Use Virginia SCC Form 216-C for expedited external review.

Does the $20 copay card work with Medicare Advantage? No, manufacturer copay cards are only for commercial insurance. Medicare patients should explore other assistance options.

What happens if I move from Virginia during treatment? Coverage continues, but appeal rights may change. Contact your new state's insurance department for external review options.

How often do I need prior authorization renewal? Typically annually, but some approvals are for shorter periods. Your specialty pharmacy will coordinate renewals.

From our advocates: We've seen patients successfully overturn Signifor LAR denials by working closely with their endocrinologist to document surgical failure and providing comprehensive biochemical evidence. The key is persistence and thorough documentation—Virginia's external review process has been particularly effective for rare disease treatments when medical necessity is clearly established.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes may vary by plan and change over time. Always consult your healthcare provider and insurance plan documents for the most current information. For personalized assistance with prior authorizations and appeals, consider consulting with coverage advocacy services like Counterforce Health, which specializes in turning insurance denials into successful approvals through evidence-based appeals.

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