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

How to Get Signifor / Signifor LAR (pasireotide) Covered by Cigna in Illinois: Prior Authorization, Appeals & Step Therapy Guide

Answer Box: Getting Signifor/Signifor LAR Covered by Cigna in Illinois

Cigna requires prior authorization for all Signifor/Signifor LAR (pasireotide) prescriptions in Illinois. For acromegaly, you must first try octreotide or lanreotide; for Cushing's disease, document surgical failure or ineligibility. Your endocrinologist must submit detailed clinical evidence including elevated IGF-1 or UFC levels, treatment history, and specialist credentials. If denied, you have 180 days for internal appeal and 30 days for external review through Illinois' independent physician review process.

First step today: Verify your Cigna plan type (HMO requires PCP referral) and ensure your endocrinologist has your complete lab results and prior treatment records ready for the PA submission.

Table of Contents

  1. Plan Types & Network Requirements
  2. Formulary Status & Coverage Tiers
  3. Prior Authorization Requirements
  4. Step Therapy & Alternative Requirements
  5. Specialty Pharmacy Setup
  6. Cost-Share Dynamics
  7. Submission Process
  8. Common Approval Strategies
  9. Appeals Process for Illinois Patients
  10. Frequently Asked Questions

Plan Types & Network Requirements

Referral Requirements by Plan Type

HMO Plans: A PCP referral is required to see an endocrinologist and maintain highest benefit coverage. The referral must be to an in-network specialist.

PPO Plans: No referrals needed. You may visit any endocrinologist without PCP approval.

EPO Plans: No referrals required. Open access to in-network specialists.

Note: Prior authorization for Signifor/Signifor LAR is separate from referrals and required regardless of plan type.

Network Considerations

Ensure your endocrinologist is in Cigna's network to avoid higher out-of-network costs. Verify network status at cigna.com or call member services.

Formulary Status & Coverage Tiers

Signifor and Signifor LAR are managed through Express Scripts specialty pharmacy as high-tier specialty medications. Both formulations require prior authorization across all Cigna commercial plans, including marketplace and employer-sponsored coverage.

Coverage Details

Aspect Requirements
Prior Authorization Required for all plans
Quantity Limit 1 vial per 28 days
Specialty Pharmacy Express Scripts/Accredo required
Prescriber Endocrinologist required
Approval Duration 12 months for initial approval

Prior Authorization Requirements

Medical Necessity by Diagnosis

For Acromegaly (Signifor LAR only):

  • Confirmed diagnosis with elevated IGF-1 levels above normal for age/gender
  • Growth hormone >5 ng/mL on separate occasions
  • Surgical failure or documented ineligibility
  • Trial and failure of octreotide LAR or lanreotide depot at maximum tolerated doses
  • Patient age 18 or older

For Cushing's Disease (both formulations):

  • ACTH-dependent hypercortisolism confirmed by laboratory testing
  • Elevated 24-hour urinary free cortisol (UFC) from at least two collections
  • Pituitary source confirmed by MRI or inferior petrosal sinus sampling
  • Surgical failure with specific documentation (operative reports, pathology results)
  • Prescription by endocrinologist

Required Documentation

Your endocrinologist must submit:

  • Complete prior authorization form with clinical rationale
  • Recent lab results (within 30 days): elevated IGF-1 or UFC levels with reference ranges
  • Detailed diagnosis with ICD-10 codes (E22.0 for acromegaly, E24.0 for Cushing's disease)
  • Treatment history with specific medications, doses, durations, and outcomes
  • Surgical history documentation (operative reports when applicable)
  • Monitoring plan for glucose levels and gallbladder function

Step Therapy & Alternative Requirements

First-Line Treatment Requirements

Acromegaly: Cigna requires documented trial and failure of:

  • Octreotide LAR (Sandostatin LAR)
  • Lanreotide depot (Somatuline Depot)

Cushing's Disease: Step therapy is less restrictive if surgery is not an option or has failed.

Documenting Treatment Failures

For each prior therapy, include:

  • Specific drug name and dosage
  • Duration of treatment (minimum trial periods vary)
  • Reason for discontinuation (lack of efficacy, intolerance, contraindication)
  • Objective measures of response (lab values, imaging)
Tip: Vague statements like "patient prefers medical management" will not meet Cigna's criteria. Provide specific clinical reasons.

Specialty Pharmacy Setup

Accredo Enrollment Process

Once approved, Signifor/Signifor LAR must be dispensed through Accredo specialty pharmacy:

  1. Prescription submission: Your prescriber faxes the completed Accredo Prescription & Enrollment Form to 888.302.1028
  2. Patient contact: Accredo calls you within 24-48 hours to arrange delivery
  3. Account setup: Create your account at Accredo.com using your Rx number
  4. Support services: Access 24/7 pharmacist support at 844.516.3319

Required Form Sections

The Accredo form requires completion of:

  • Patient information and insurance details
  • Prescriber information with NPI
  • Clinical information including ICD-10 code
  • Prescribing information with dosing

Cost-Share Dynamics

Estimated Costs

Signifor LAR costs approximately $20,000+ per vial, making cost-sharing significant even with insurance coverage. Your out-of-pocket costs depend on:

  • Plan deductible (specialty drugs may have separate deductibles)
  • Coinsurance percentage for specialty tiers (typically 20-40%)
  • Annual out-of-pocket maximums

Financial Assistance Options

Manufacturer Support: Recordati Rare Diseases may offer patient assistance programs (verify current programs at their official website).

Foundation Grants: Organizations like the Patient Access Network Foundation provide grants for rare disease medications.

Submission Process

Timeline Expectations

  • Standard PA review: 5-15 business days
  • Urgent requests: 72 hours (requires medical urgency documentation)
  • Appeals processing: 30 days for internal review

Submission Methods

Your endocrinologist can submit via:

  • Cigna provider portal (preferred method)
  • Fax to specialty pharmacy PA department
  • Phone: 1-866-494-2111 for urgent cases

Common Approval Strategies

Strengthening Your PA Submission

Clinical Documentation Best Practices:

  • Include complete lab panels with reference ranges
  • Provide detailed surgical history with operative reports
  • Document specific reasons for treatment failures
  • Include current treatment goals and monitoring plan

Evidence-Based Support:

  • Reference FDA labeling for approved indications
  • Cite Endocrine Society guidelines
  • Include peer-reviewed literature for complex cases
From our advocates: We've seen PA approvals significantly improve when endocrinologists include a clear timeline showing why surgery failed or isn't appropriate, along with specific lab values demonstrating inadequate disease control. The key is being concrete rather than general in your clinical justification.

Appeals Process for Illinois Patients

Internal Appeal Timeline

If your PA is denied, you have 180 calendar days to file an internal appeal with Cigna. The review process includes:

  1. Level 1 Review: Medical director review within 30 days
  2. Peer-to-Peer Option: Request direct physician consultation
  3. Level 2 Review: Independent physician review if Level 1 denied

Illinois External Review

After exhausting internal appeals, Illinois residents can request an independent external review:

  • Deadline: 30 days from final internal denial (stricter than many states)
  • Process: Independent Review Organization (IRO) with board-certified physician
  • Timeline: Decision within 5 business days of receiving records
  • Cost: Free to patients; insurers pay review costs
  • Binding: IRO decisions are final and binding on Cigna

Illinois Resources

Illinois Department of Insurance:

  • Consumer hotline: 877-527-9431
  • External review assistance and forms
  • doi.illinois.gov for complaint filing

Illinois Attorney General Health Care Bureau:

  • Helpline: 877-305-5145
  • Can intervene informally with insurers

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with Cigna's specific requirements, incorporating the right clinical evidence and procedural documentation to maximize approval chances.

Frequently Asked Questions

How long does Cigna prior authorization take for Signifor/Signifor LAR in Illinois? Standard reviews take 5-15 business days. Urgent requests with documented medical necessity are processed within 72 hours.

What if Signifor/Signifor LAR is denied for "not medically necessary"? Request a peer-to-peer review with Cigna's medical director. Ensure your endocrinologist has complete biochemical evidence and documented treatment failures.

Does step therapy apply if I tried octreotide outside Illinois? Yes, documented treatment history from any state counts toward step therapy requirements, provided you have complete records.

Can I get expedited approval for Signifor/Signifor LAR? Yes, if delay would seriously jeopardize your health. Your endocrinologist must document medical urgency and submit supporting clinical evidence.

What happens if my external review is approved in Illinois? The decision is binding on Cigna. They must authorize coverage and cannot appeal the IRO's medical determination.

How do I verify my Cigna plan's specific requirements? Log into myCigna or call the member services number on your insurance card. Each plan may have slight variations in coverage details.

What if my endocrinologist isn't familiar with Cigna's PA process? Counterforce Health's platform helps clinicians navigate payer-specific requirements and generates compliant PA submissions with proper clinical documentation.

Are there quantity limits beyond the standard 1 vial per 28 days? Higher quantities require additional clinical justification. Document if standard dosing is inadequate based on clinical response and monitoring.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage policies vary by plan and may change. Always verify current requirements with Cigna directly and consult your healthcare provider for medical decisions. For personalized assistance with prior authorization and appeals, contact the Illinois Department of Insurance or qualified patient advocacy services.

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