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

How to Get Signifor LAR (Pasireotide) Covered by Humana in Washington: Appeals Guide with Forms and Timelines

Answer Box: Getting Signifor LAR Covered by Humana in Washington

Humana requires prior authorization for Signifor LAR (pasireotide) in 2024. For Cushing's disease or acromegaly patients in Washington, the fastest path to approval involves: (1) Your endocrinologist submitting a complete prior authorization request through Humana's provider portal with documented surgical failure or contraindication, (2) including comprehensive lab results (UFC for Cushing's, IGF-1 for acromegaly), and (3) for acromegaly, proving failure or intolerance of first-line somatostatin analogs. If denied, Washington residents have strong appeal rights including external review by an Independent Review Organization (IRO) within 60 days.

Table of Contents

  1. Understanding Humana's Prior Authorization Requirements
  2. Medical Necessity Criteria for Signifor LAR
  3. Step-by-Step: Fastest Path to Approval
  4. Common Denial Reasons & How to Fix Them
  5. Appeals Playbook for Washington Residents
  6. Templates and Scripts
  7. When to Contact Washington's Insurance Commissioner
  8. Cost Assistance Options
  9. FAQ

Understanding Humana's Prior Authorization Requirements

Signifor LAR (pasireotide) is classified as a high-cost specialty medication requiring prior authorization under all Humana Medicare Advantage plans in 2024. The medication, which can cost over $20,000 per vial, treats Cushing's disease when surgery isn't an option and acromegaly inadequately controlled by surgery or first-generation somatostatin analogs.

Coverage at a Glance:

Requirement Details Where to Find Source
Prior Authorization Required for all indications Humana PA Search Tool Humana Provider Portal
Formulary Status Specialty tier, non-formulary on most plans Member formulary document Plan-specific
Prescriber Requirements Board-certified endocrinologist preferred PA criteria documentation Medical necessity guidelines
Site of Care Specialty pharmacy required Humana specialty network Provider manual
Appeals Deadline 60 days from denial (Washington) Denial letter Washington OIC

Medical Necessity Criteria for Signifor LAR

Based on current endocrinology guidelines and payer policies, Signifor LAR is considered medically necessary when specific criteria are met:

For Cushing's Disease:

  • Confirmed ACTH-dependent Cushing's syndrome with elevated urinary free cortisol (UFC)
  • Documented failure of pituitary surgery OR surgery contraindicated/not feasible
  • Evaluation by board-certified endocrinologist
  • No severe hepatic impairment (Child-Pugh C)

For Acromegaly:

  • Confirmed diagnosis with elevated IGF-1 and failed glucose suppression test
  • Inadequate response to surgery or surgery not an option
  • Critical requirement: Documented failure or intolerance of first-line somatostatin analogs (octreotide LAR, lanreotide)
  • Dose typically limited to 60 mg every 4 weeks
Clinician Corner: Medical necessity letters should include specific lab values, dates of prior treatments, and clear documentation of why alternatives failed or are contraindicated. Reference FDA labeling and current Endocrine Society guidelines for strongest clinical justification.

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient/Clinic)

  • Recent lab results (UFC, late-night salivary cortisol for Cushing's; IGF-1, OGTT for acromegaly)
  • Surgical records or contraindication documentation
  • Prior medication trials with outcomes and adverse events
  • Current endocrinology consultation notes

2. Submit Prior Authorization (Prescriber)

  • Use Humana's provider portal or fax to 877-486-2621
  • Include completed PA form with all supporting clinical documentation
  • Timeline: Humana commits to 1-business day turnaround for complete electronic submissions

3. Track Your Request (Patient/Clinic)

  • Monitor through provider portal or call Humana member services
  • Standard determination: 72 hours for formulary exceptions
  • Expedited: 24 hours if health would be seriously jeopardized

4. If Approved (Patient)

  • Fill at Humana-contracted specialty pharmacy
  • Coordinate delivery and injection scheduling
  • Monitor for required lab work (glucose, gallbladder function)

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
"Not FDA-approved indication" Submit FDA label excerpt showing approved use FDA Access Data for Signifor LAR
"First-line therapy not tried" (acromegaly) Document octreotide/lanreotide failure or contraindication Prior therapy records, adverse event notes
"Insufficient biochemical evidence" Provide recent hormone levels with reference ranges Lab reports within 3 months
"Surgery should be attempted first" Submit surgical consultation or contraindication letter Neurosurgery evaluation, imaging reports
"Non-specialist prescriber" Transfer care or obtain co-signature from endocrinologist Board certification verification

Appeals Playbook for Washington Residents

Washington offers robust consumer protections for insurance denials. If Humana denies your Signifor LAR request:

Level 1: Internal Appeal (Redetermination)

  • Deadline: 60 days from denial notice
  • Submit to: Humana appeals department (address on denial letter)
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Required: Additional clinical evidence, prescriber letter addressing specific denial reasons

Level 2: External Review (IRO)

  • Eligibility: After completing internal appeal or if Humana fails to respond timely
  • Deadline: 60 days from final internal denial
  • Process: Request through Humana, who assigns state-certified Independent Review Organization
  • Timeline: 20 days for standard review, 72 hours for expedited
  • Outcome: IRO decision is binding on Humana

Washington-Specific Advantages:

From our advocates: We've seen Washington patients successfully overturn Signifor LAR denials by emphasizing the state's external review process in their initial appeals. One composite case involved a Cushing's patient whose denial was overturned when the IRO found Humana's surgical requirement unreasonable given the patient's specific contraindications. While outcomes vary, Washington's independent review system provides genuine oversight.

Templates and Scripts

Medical Necessity Letter Template (for prescribers):

Re: Prior Authorization Request - Signifor LAR (pasireotide) for [Patient Name]

Dear Humana Medical Review Team,

I am requesting coverage for Signifor LAR 40mg every 4 weeks for my patient with [Cushing's disease/acromegaly] based on the following medical necessity:

DIAGNOSIS: [Specific diagnosis with ICD-10 code]
- Biochemical confirmation: [specific lab values and dates]
- Duration of disease: [timeline]

PRIOR TREATMENTS:
- Surgical history: [details of pituitary surgery or contraindications]
- [For acromegaly] Previous somatostatin analogs: [octreotide/lanreotide trials with doses, duration, outcomes]
- Other therapies attempted: [list with results]

CLINICAL RATIONALE:
Signifor LAR is medically necessary because [specific reasons why alternatives are inadequate]. The patient meets FDA-approved indications and current Endocrine Society guidelines for this therapy.

Supporting documentation attached includes recent lab work, surgical records, and prior medication trial summaries.

Sincerely,
[Provider name, credentials, NPI]

Patient Phone Script for Humana:

"Hello, I'm calling about prior authorization status for Signifor LAR. My member ID is [number]. Can you tell me the current status and if any additional information is needed? If denied, I'd like to understand the specific reasons and my appeal rights under Washington state law."

When to Contact Washington's Insurance Commissioner

Contact the Washington Office of the Insurance Commissioner at 800-562-6900 if:

  • Humana fails to respond within required timelines
  • You need help understanding your appeal rights
  • The denial appears to violate Washington insurance laws
  • You want assistance preparing for external review

The OIC's Consumer Advocacy Program can provide templates, intervene with insurers, and guide you through Washington's external review process.

Cost Assistance Options

Manufacturer Support:

  • Recordati Rare Diseases may offer patient assistance programs
  • Specialty pharmacy copay assistance programs
  • Clinical trial opportunities for eligible patients

Foundation Resources:

  • National Organization for Rare Disorders (NORD) medication assistance
  • Patient Access Network Foundation specialty drug grants
  • Cushing's Support & Research Foundation resources

Washington State Programs:

  • Apple Health (Medicaid) for eligible low-income residents
  • Washington State Prescription Drug Program for seniors

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by analyzing denial letters and crafting evidence-backed rebuttals. Their platform identifies the specific denial basis and provides targeted responses aligned with each payer's own policies, potentially saving months of back-and-forth appeals.

FAQ

Q: How long does Humana prior authorization take for Signifor LAR? A: Humana commits to 1-business day for complete electronic submissions, with 72 hours maximum for formulary exceptions and 24 hours for expedited requests.

Q: What if Signifor LAR isn't on my Humana formulary? A: You can request a formulary exception with prescriber support. If denied, Washington residents have strong appeal rights including external review.

Q: Can I request an expedited appeal in Washington? A: Yes, if delay would seriously jeopardize your health. Both Humana internal appeals and Washington IRO external reviews offer expedited timelines (72 hours).

Q: Does step therapy apply if I've tried other medications outside Washington? A: Prior therapy records from any state typically count toward step therapy requirements. Ensure all documentation is submitted with your PA request.

Q: What happens if the IRO upholds Humana's denial? A: IRO decisions are binding, but you may still pursue legal action or explore alternative coverage options like manufacturer assistance programs.

Q: Who pays for external review in Washington? A: External review is provided at no cost to consumers under Washington state law.

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Treatment decisions should always be made in consultation with qualified healthcare providers. Coverage policies vary by plan and individual circumstances.

Sources & Further Reading:

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