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

How to Get Signifor/Signifor LAR Covered by UnitedHealthcare in Illinois: Complete Guide to Prior Authorization, Appeals & Forms

Quick Answer: Getting Signifor/Signifor LAR Covered by UnitedHealthcare in Illinois

UnitedHealthcare requires prior authorization for Signifor (pasireotide) in Illinois. For Cushing's disease: coverage is approved when pituitary surgery isn't an option or hasn't been curative—no step therapy required. For acromegaly: you must first fail or be unable to tolerate octreotide or lanreotide. Submit through the UHC Provider Portal with complete diagnosis documentation. If denied, Illinois law gives you strong appeal rights, including external review within 30 days of final denial through the Illinois Department of Insurance.

First step today: Have your endocrinologist gather surgical history and prior treatment records, then submit the PA request with all supporting documentation.

Table of Contents

Plan Types & Coverage Implications

UnitedHealthcare offers several plan types in Illinois, each with different implications for Signifor coverage:

Commercial Plans (Employer-Sponsored)

  • HMO plans may require referrals to endocrinologists
  • PPO plans typically allow direct specialist access
  • All commercial plans require prior authorization for Signifor
  • Network restrictions apply—verify your endocrinologist is in-network

Medicare Advantage

  • Prior authorization required as of September 2024
  • May have different formulary tiers than commercial plans
  • Appeals follow Medicare guidelines with Illinois state protections

Medicaid Managed Care

  • Coverage varies by managed care organization
  • May have additional state-specific requirements
  • Prior authorization always required
Note: Illinois has expanded Medicaid, leading to broader coverage options for eligible patients.

Formulary Status & Tier Placement

Coverage at a Glance

Requirement Cushing's Disease Acromegaly Source
Prior Authorization Yes Yes UHC Policy
Step Therapy No Yes (try octreotide/lanreotide first) UHC Policy
Formulary Tier Specialty (Tier 4-5) Specialty (Tier 4-5) Verify with specific plan
Age Restriction 18+ years 18+ years UHC Policy
Prescriber Requirement Endocrinologist preferred Endocrinologist preferred Clinical best practice

Alternative Agents on Formulary:

  • For acromegaly: Octreotide LAR (Sandostatin LAR), lanreotide (Somatuline Depot), pegvisomant (Somavert)
  • For Cushing's disease: Osilodrostat (Isturisa), mifepristone (Korlym), ketoconazole

Prior Authorization Requirements

Step-by-Step: Fastest Path to Approval

  1. Confirm Diagnosis (Endocrinologist)
    • Document biochemical confirmation of Cushing's disease or acromegaly
    • Include relevant labs: 24-hour urinary free cortisol, IGF-1, growth hormone levels
    • Timeline: Same visit as treatment decision
  2. Document Surgical History (Endocrinologist)
    • For Cushing's: Pituitary surgery not curative OR patient not a surgical candidate
    • For acromegaly: Inadequate response to surgery OR ineligible for surgery
    • Timeline: Include in PA submission
  3. Complete Step Therapy Requirements (For Acromegaly Only)
    • Document trial and failure of octreotide LAR or lanreotide
    • Include specific reasons for failure: lack of efficacy, intolerable side effects, contraindications
    • Timeline: Must be documented before Signifor approval
  4. Gather Baseline Testing (Clinic Staff)
    • Fasting glucose, HbA1c, liver function tests
    • ECG, gallbladder ultrasound
    • Serum potassium and magnesium levels
    • Timeline: Within 6 months of PA submission
  5. Submit Prior Authorization (Provider)
    • Use UHC Provider Portal or call 800-903-5253
    • Include all supporting documentation
    • Timeline: Submit 7-10 business days before needed
  6. Follow Up (Clinic Staff)
    • Check status via provider portal
    • Prepare for potential peer-to-peer review
    • Timeline: UHC responds within 15 business days for standard requests
  7. Initiate Specialty Pharmacy (Patient/Clinic)
    • Work with UHC-preferred specialty pharmacy
    • Complete patient enrollment and insurance verification
    • Timeline: 3-5 business days after PA approval

Medical Necessity Documentation Checklist

Required for All Requests:

  • Confirmed diagnosis by board-certified endocrinologist
  • ICD-10 codes: E24.0 (Cushing's disease), E22.0 (acromegaly)
  • Baseline laboratory values and imaging
  • Documentation of surgical history or ineligibility
  • Patient age verification (18+ years)

Additional for Acromegaly:

  • Trial and documented failure of first-generation somatostatin analog
  • Specific reasons for treatment failure
  • Contraindication documentation if applicable

Specialty Pharmacy Requirements

UnitedHealthcare typically routes Signifor through OptumRx specialty pharmacy network:

Patient Setup Process:

  1. Provider sends prescription to UHC-designated specialty pharmacy
  2. Pharmacy contacts patient for insurance verification
  3. Patient completes enrollment forms and provides payment method
  4. Pharmacy coordinates delivery (typically monthly for LAR formulation)
  5. Ongoing clinical monitoring through pharmacy support team

Key Points:

  • Cannot use retail pharmacy for Signifor
  • Specialty pharmacy provides injection training for LAR formulation
  • Patient support services include copay assistance coordination
  • Refrigerated shipping required—ensure someone is available for delivery

Cost-Share Basics

Signifor is typically placed on specialty tiers (Tier 4-5) with higher cost-sharing:

Typical Cost Structure (Educational—verify with your specific plan):

  • Deductible: May need to be met before coverage begins
  • Specialty copay: Often $50-$200+ per month or 20-40% coinsurance
  • Out-of-pocket maximum: Specialty medications count toward annual limit

Cost-Saving Options:

From our advocates: "One patient saved over $15,000 annually by combining manufacturer copay assistance with their employer's specialty pharmacy benefits. The key was working with both the specialty pharmacy and manufacturer support team to maximize available programs—something many patients don't realize they can do simultaneously."

Submission Process

Provider Portal Submission

Access: UHC Provider Portal

  • Log in with One Healthcare ID
  • Navigate to Prior Authorization and Notification tool
  • Select "Specialty Medications"

Required Information:

  • Patient demographics and insurance information
  • Prescriber NPI and specialty
  • Drug details: NDC, strength, quantity, days supply
  • Diagnosis codes (ICD-10)
  • Clinical documentation upload

Alternative Methods:

  • Phone: 800-903-5253
  • Fax: 855-225-9847
  • Expedited requests: Submit electronically with urgent clinical justification

Common Approval Patterns

What Strong Submissions Include

Successful Cushing's Disease Requests:

  • Clear biochemical evidence of hypercortisolism
  • Detailed surgical history with post-operative hormone levels
  • Documentation that surgery was not curative (persistent elevated cortisol)
  • Baseline metabolic panel within 6 months

Successful Acromegaly Requests:

  • Elevated IGF-1 and growth hormone levels
  • Surgical history with inadequate biochemical control
  • Specific documentation of octreotide/lanreotide trial with doses, duration, and response
  • Clear statement of side effects or contraindications to first-generation analogs

Common Denial Reasons & Fixes

Denial Reason How to Overturn Documentation Needed
Insufficient diagnosis documentation Resubmit with complete lab values Biochemical confirmation, imaging studies
Missing step therapy for acromegaly Document first-generation analog failure Treatment records, response data, side effect documentation
Prescriber not specialist Get endocrinologist consultation Specialist evaluation, treatment recommendation
Missing baseline testing Complete required labs/imaging Glucose, liver function, ECG, gallbladder ultrasound

Appeals Process in Illinois

Illinois provides strong patient protections for insurance denials, with specific timelines that differ from federal minimums.

Internal Appeals (UnitedHealthcare)

Timeline: Must request within 180 days of denial for most plans Process:

  1. Submit appeal through UHC Provider Portal
  2. Include additional clinical documentation
  3. Request peer-to-peer review if appropriate
  4. UHC responds within 15 business days (standard) or 72 hours (urgent)

Required Documentation:

  • Copy of original denial letter
  • Additional clinical evidence supporting medical necessity
  • Updated treatment notes or lab values
  • Specialist recommendations

External Review (Illinois Department of Insurance)

Critical Timeline: Must request within 30 days of final internal denial (shorter than federal 4-month window)

Process:

  1. Contact Illinois Department of Insurance at 877-527-9431
  2. Complete external review application
  3. Submit all medical records and denial correspondence
  4. Independent physician reviewer makes binding decision within 5 business days

What Qualifies:

  • Medical necessity disputes
  • Coverage determination denials
  • Treatment authorization denials
Important: Illinois's 30-day external review deadline is stricter than many states—don't wait to file if your internal appeal is denied.

FAQ

How long does UnitedHealthcare prior authorization take in Illinois? Standard requests: 15 business days. Expedited requests: 72 hours. Submit early to avoid treatment delays.

What if Signifor is non-formulary on my plan? Request a formulary exception with medical necessity documentation. Include clinical evidence why covered alternatives are inappropriate.

Can I request an expedited appeal? Yes, if delay would seriously jeopardize your health. Submit with urgent clinical justification and expected timeline for harm.

Does step therapy apply if I tried first-generation analogs outside Illinois? Yes, prior treatment history from any location counts. Provide complete documentation from previous providers.

What's the difference between Signifor and Signifor LAR coverage? LAR (long-acting) formulation has additional acromegaly indication and may have different tier placement. Both require prior authorization.

Who can prescribe Signifor for UnitedHealthcare coverage? Any licensed physician, but endocrinologist prescriptions have higher approval rates due to specialty expertise.

What if my employer plan has different rules? Self-funded employer plans may have modified coverage criteria. Check your specific plan documents or contact HR benefits.

Can I appeal if I'm on Medicare Advantage? Yes, Medicare Advantage appeals follow both Medicare and Illinois state protections. You have the same external review rights.

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform ingests denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to each payer's specific rules, pulling the right citations and weaving them into appeals with required clinical facts and operational details.

For complex cases requiring additional support, Counterforce Health provides comprehensive appeal assistance, helping transform denials into approvals through systematic, evidence-based advocacy.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan benefits and clinical circumstances. Always verify current policies with UnitedHealthcare and consult your healthcare provider for medical guidance. For personalized assistance with insurance appeals in Illinois, contact the Illinois Department of Insurance Office of Consumer Health Insurance at 877-527-9431.

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