How to Get Signifor / Signifor LAR (pasireotide) Covered by Aetna (CVS Health) in Washington: Complete Prior Authorization and Appeals Guide
Answer Box: Your Fastest Path to Coverage
Aetna (CVS Health) requires prior authorization for Signifor / Signifor LAR (pasireotide) and lists it as non-preferred, with Somatuline Depot as the preferred alternative. Washington members have strong appeal rights through the Office of Insurance Commissioner and binding external review. Your first step today: Call your endocrinologist to request Aetna's precertification form and gather documentation of failed first-line treatments. Submit via CVS Specialty at 1-855-240-0535 or fax 1-888-267-3277. If denied, you have 120 days for external review through Washington's Independent Review Organization process.
Table of Contents
- Why Washington State Rules Matter
- Prior Authorization Requirements
- Step-by-Step: Fastest Path to Approval
- Step Therapy Protections in Washington
- Appeals Playbook for Aetna in Washington
- Common Denial Reasons & How to Fix Them
- When to Escalate to State Regulators
- Costs & Patient Assistance Programs
- FAQ
Why Washington State Rules Matter
Washington offers some of the strongest patient protections in the nation for insurance appeals. The Specialist Care Access Act, effective March 2025, requires appeals involving specialist care to be reviewed by physicians in the same or related specialty. This is crucial for Signifor / Signifor LAR (pasireotide), as endocrine specialists understand the complex treatment algorithms for Cushing's disease and acromegaly that general reviewers might miss.
Key Washington protections include:
- External Review Rights: Independent Review Organizations (IROs) can overturn Aetna denials with binding decisions
- 120-day appeal window for external review after final internal denial
- Specialist-to-specialist review for denials involving specialist care
- Consumer advocacy line at 1-800-562-6900 for step-by-step guidance
Important: These protections apply to fully insured commercial plans and Washington Healthplanfinder coverage. Self-funded ERISA employer plans are governed by federal law and may have different procedures.
Prior Authorization Requirements
Aetna requires comprehensive clinical documentation for Signifor / Signifor LAR approval. CVS Specialty handles prior authorization for Aetna members through their dedicated process.
Coverage at a Glance
| Requirement | What It Means | Where to Find It |
|---|---|---|
| Prior Authorization | Required for all Signifor formulations | Aetna Precertification Form |
| Formulary Status | Non-preferred (Somatuline Depot preferred) | Aetna Specialty Drug List |
| Step Therapy | Required trial of preferred agents | Medical exception process available |
| Prescriber | Endocrinologist or specialist required | Clinical documentation needed |
| Diagnosis Codes | E24.0 (Cushing's), E22.0 (Acromegaly) | ICD-10 documentation required |
Step-by-Step: Fastest Path to Approval
1. Confirm Your Plan Type
Who: You (patient)
Action: Call Aetna member services (number on your insurance card) to confirm whether you have fully insured or self-funded coverage
Timeline: 5 minutes
Why it matters: Determines which Washington protections apply
2. Gather Clinical Documentation
Who: Your endocrinologist
Documents needed:
- Confirmed diagnosis with ICD-10 codes
- Documentation that surgery failed or isn't an option
- Laboratory results (UFC, IGF-1, cortisol levels) within 6 months
- Records of failed first-line treatments (octreotide, lanreotide, or Somatuline Depot)
- Letter of medical necessity
3. Submit Prior Authorization Request
Who: Your doctor's office
Method: Fax to CVS Specialty: 1-888-267-3277 or call 1-855-240-0535
Form: Aetna Signifor LAR Precertification Request
Timeline: Standard review within 30-45 days; expedited within 72 hours if urgent
4. Track Your Request
Action: Call CVS Specialty to confirm receipt and get reference number
Follow-up: Check status weekly if no response within expected timeframe
5. Prepare for Potential Denial
Action: If denied, immediately request detailed denial letter citing specific policy sections
Next steps: Begin internal appeal process within plan timelines
Step Therapy Protections in Washington
Washington requires health plans to provide a clear, accessible process for step therapy overrides when:
- The preferred drug is contraindicated
- You've experienced intolerable side effects
- The preferred drug failed after a reasonable trial
For Signifor / Signifor LAR appeals, document:
- Prior treatment failures with octreotide, lanreotide, or Somatuline Depot
- Specific adverse reactions to preferred agents (with dates and severity)
- Clinical reasons why alternatives are medically inappropriate
- Contraindications to first-line therapies
From our advocates: We've seen many Cushing's disease patients successfully appeal step therapy requirements by providing detailed documentation of hyperglycemia or cardiac complications from first-generation somatostatin analogs. The key is having your endocrinologist clearly explain why pasireotide's unique SSTR5 selectivity makes it medically necessary for your specific case.
Appeals Playbook for Aetna in Washington
Internal Appeals Process
| Appeal Level | Timeline | How to Submit | Required Documents |
|---|---|---|---|
| First Internal | File within 180 days of denial | Written request to Aetna | Denial letter, medical records, prescriber attestation |
| Second Internal | Automatic if first denied | Aetna handles internally | Additional clinical evidence if available |
| Expedited | 72 hours if urgent | Mark "URGENT" on all forms | Documentation of serious health jeopardy |
External Review Process
After exhausting internal appeals, Washington members can request binding external review through an Independent Review Organization (IRO).
Key details:
- Deadline: 120 days from final internal denial
- Process: Submit request to Aetna or directly to Washington Office of Insurance Commissioner
- Timeline: 20 days for fully insured plans; up to 45 days for self-insured
- Cost: Free to you
- Decision: Binding on Aetna if overturned
To request external review:
- Contact the Washington Office of Insurance Commissioner at 1-800-562-6900
- Submit all relevant medical records and denial documentation
- Include a statement explaining why the denial was inappropriate
- Reference Washington's Specialist Care Access Act for specialist review
Common Denial Reasons & How to Fix Them
| Denial Reason | How to Overturn |
|---|---|
| "Not medically necessary" | Submit peer-reviewed studies showing pasireotide's efficacy for your specific diagnosis; reference FDA labeling |
| "Step therapy not completed" | Document failed trials of octreotide/lanreotide with specific dates, dosages, and reasons for discontinuation |
| "Non-formulary drug" | Request formulary exception with clinical justification; cite unique mechanism of action (SSTR5 selectivity) |
| "Experimental/investigational" | Provide FDA approval documentation; reference indication-specific labeling for Cushing's disease or acromegaly |
| "Quantity limits exceeded" | Submit dosing rationale based on patient weight, disease severity, and response to treatment |
When to Escalate to State Regulators
Contact the Washington Office of Insurance Commissioner if:
- Aetna fails to respond within required timelines
- Appeals are reviewed by non-specialists (cite Specialist Care Access Act)
- You suspect the denial violates Washington insurance law
- The external review process is mishandled
Washington OIC Consumer Advocacy: 1-800-562-6900
Online complaint form: Available at the OIC website
What to include: Policy number, denial letters, timeline of communications, specific law violations
For patients navigating complex prior authorization requirements and appeals, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters, identifies the specific basis for rejection, and drafts point-by-point rebuttals aligned to each plan's own rules, helping patients and clinicians get prescription drugs approved more efficiently.
Costs & Patient Assistance Programs
Estimated costs: Signifor LAR can exceed $20,000 per vial, making insurance coverage critical for most patients.
Financial assistance options:
- Recordati Patient Assistance Program: Contact manufacturer directly for eligibility
- Foundation grants: Patient Access Network Foundation, HealthWell Foundation
- State programs: Washington Apple Health (Medicaid) for eligible individuals
- Copay assistance: May be available for commercially insured patients
Note: Patient assistance programs typically cannot be combined with government insurance (Medicare, Medicaid).
FAQ
How long does Aetna prior authorization take for Signifor LAR in Washington?
Standard review takes 30-45 days. Expedited review (if urgent) is completed within 72 hours. Washington law requires insurers to meet these timelines.
What if Signifor LAR is non-formulary on my Aetna plan?
You can request a formulary exception with clinical justification. Document why preferred alternatives (Somatuline Depot) are inappropriate for your case.
Can I request an expedited appeal if I'm already on Signifor LAR?
Yes, if interruption of treatment would seriously jeopardize your health. Provide documentation from your endocrinologist explaining the medical urgency.
Does step therapy apply if I failed treatments outside of Washington?
Yes, prior treatment failures from other states count toward step therapy requirements. Ensure your new Washington provider has complete medical records.
What's the difference between internal and external review?
Internal appeals are handled by Aetna. External review involves an independent organization that can make binding decisions overruling Aetna's denial.
How do I know if I have a fully insured or self-funded plan?
Call Aetna member services or check your Summary Plan Description. Fully insured plans have stronger Washington state protections.
Sources & Further Reading
- Aetna Signifor LAR Precertification Form
- Washington Office of Insurance Commissioner Consumer Advocacy
- CVS Specialty Prior Authorization Contacts
- Washington Specialist Care Access Act Information
- FDA Signifor LAR Prescribing Information
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies vary, and coverage decisions depend on individual circumstances. Always consult with your healthcare provider and insurance company for specific guidance. For personalized assistance with insurance appeals, consider consulting with Counterforce Health or other qualified advocates who specialize in prior authorization and appeals processes.
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