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

How to Get Signifor / Signifor LAR (Pasireotide) Covered by UnitedHealthcare in California: Complete Prior Authorization Guide

Answer Box: Getting Signifor Covered by UnitedHealthcare in California

UnitedHealthcare requires prior authorization for Signifor (pasireotide) with board-certified endocrinologist involvement and specific biochemical documentation. For Cushing's disease, no step therapy is required—just proof of endogenous hypercortisolism and surgical ineligibility/failure. Submit requests through the UHC Provider Portal with 24-hour UFC levels, complete surgical history, and baseline labs. If denied, California's Independent Medical Review (IMR) offers strong appeal rights. First step today: Have your endocrinologist gather your complete medical records and lab results, then submit the PA request 7-10 days before you need the medication.

Table of Contents

Plan Types & Coverage Implications

UnitedHealthcare operates several plan types in California, each with different network requirements and referral rules that affect Signifor access:

Commercial Plans (HMO/PPO/EPO)

  • HMO plans require primary care referrals to endocrinologists
  • PPO plans allow direct specialist access but may have higher out-of-network costs
  • All plan types require prior authorization for Signifor through OptumRx

Medicare Advantage

  • Subject to UnitedHealthcare's Medicare Part D formulary
  • May have additional Medicare-specific documentation requirements
  • Appeals follow both UnitedHealthcare and Medicare timelines

Medicaid (Partnership Plans)

  • Coverage through California's Medicaid managed care contracts
  • May have state-specific formulary additions or restrictions
  • Appeals subject to both state Medicaid and UnitedHealthcare procedures
Note: Regardless of plan type, all Signifor requests require endocrinologist involvement and go through the same prior authorization process.

Formulary Status & Tier Placement

Signifor is typically placed on Tier 4-5 (specialty tier) across UnitedHealthcare's California formularies, meaning higher cost-sharing but guaranteed coverage when medically necessary.

Current Status (2024-2025)

  • Signifor (immediate-release): Tier 4/5 specialty drug
  • Signifor LAR (long-acting): Tier 4/5 specialty drug
  • Prior authorization: Required for all formulations
  • Quantity limits: Yes, based on FDA-approved dosing

Alternative Agents on Formulary For acromegaly patients, UnitedHealthcare typically covers these alternatives with potentially lower tiers:

  • Octreotide LAR (Sandostatin LAR)
  • Lanreotide (Somatuline Depot)
  • Pegvisomant (Somavert) - for growth hormone receptor antagonism

For Cushing's disease, alternatives may include:

  • Osilodrostat (Isturisa)
  • Mifepristone (Korlym)

Prior Authorization Requirements

UnitedHealthcare's prior authorization policy for Signifor became effective January 1, 2025, with specific criteria for each indication.

Coverage Criteria by Indication

Cushing's Disease

  • Confirmed diagnosis of endogenous hypercortisolism (not medication-induced)
  • Either pituitary surgery was not curative OR patient is not a surgical candidate
  • No step therapy required
  • Must be prescribed by board-certified endocrinologist

Acromegaly (Signifor LAR only)

  • Confirmed diagnosis with elevated IGF-1 levels or abnormal GH suppression test
  • Inadequate response to surgery, radiotherapy, or dopamine agonists OR patient not a candidate for these treatments
  • May require trial of first-generation somatostatin analogs first

Required Documentation

Document Type Cushing's Disease Acromegaly Where to Find
24-hour urinary free cortisol ✓ Required Not specified Lab results within 6 months
IGF-1 levels Not specified ✓ Required Lab results within 6 months
Growth hormone levels Not specified ✓ Required Lab results within 6 months
Surgical history ✓ Required ✓ Required Operative reports, pathology
Baseline labs ✓ Required ✓ Required Glucose, HbA1c, LFTs, electrolytes
ECG ✓ Required ✓ Required Within 6 months
Gallbladder ultrasound ✓ Required ✓ Required Within 6 months

Specialty Pharmacy Network

California UnitedHealthcare members must use designated specialty pharmacies for Signifor dispensing:

Primary Options

  • Accredo Specialty Pharmacy
  • Optum Specialty Pharmacy

Setup Process

  1. Obtain prior authorization approval first
  2. Prescriber sends prescription to chosen specialty pharmacy
  3. Pharmacy contacts patient to coordinate delivery
  4. Initial shipment typically arrives within 3-5 business days after approval
Tip: Contact your chosen specialty pharmacy directly after PA approval to expedite the setup process and discuss delivery preferences.

Cost-Share Dynamics

As a specialty tier medication, Signifor typically involves significant cost-sharing under UnitedHealthcare plans:

Typical Cost Structure

  • Deductible: May apply before copay/coinsurance kicks in
  • Copay/Coinsurance: Often 25-40% coinsurance for specialty drugs
  • Out-of-pocket maximum: Counts toward annual limit

Cost-Saving Options

Note: This is educational information only. Verify your specific plan's cost-sharing through your member portal or by calling member services.

Submission Process & Forms

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic)
    • Complete medical records including surgical history
    • All required lab results within 6 months
    • Prior therapy documentation if applicable
    • Timeline: 1-2 days
  2. Complete PA Request (Prescriber)
    • Log into UHC Provider Portal
    • Submit prior authorization with all supporting documents
    • Include physician attestation confirming medical necessity
    • Timeline: Submit 7-10 days before medication needed
  3. UnitedHealthcare Review (Automatic)
    • Standard review: 15 business days
    • Expedited review available for urgent cases
    • Timeline: 1-15 business days
  4. Approval & Pharmacy Setup (Patient/Clinic)
    • If approved, coordinate with Accredo or Optum Specialty
    • Complete pharmacy intake and insurance verification
    • Timeline: 3-5 business days for first shipment

Required Forms & Portals

Primary Submission Methods

  • Online: UHC Provider Portal (preferred method)
  • Phone: 800-903-5253 for provider services
  • Fax: Available through provider portal (verify current number)

Key Form Fields

  • ICD-10 codes: E24.0 (Cushing's disease) or E22.0 (acromegaly)
  • Complete prescriber information including NPI and specialty
  • Detailed clinical rationale with guideline references
  • Patient age verification (18+ required)

Common Approval Patterns

Based on UnitedHealthcare's policy requirements, successful submissions typically include:

Medical Necessity Letter Checklist

Clinical Documentation

  • Confirmed endocrine diagnosis with appropriate biochemical testing
  • Complete surgical history or documented ineligibility for surgery
  • Failed/contraindicated alternative treatments (for acromegaly)
  • Baseline safety monitoring completed

Supporting Evidence

  • Reference to FDA prescribing information
  • Endocrine Society clinical practice guidelines
  • Patient-specific dosing rationale
  • Monitoring plan for known side effects
From our advocates: We've seen the strongest approvals come from endocrinologists who clearly document why surgery failed or isn't feasible, include all the required baseline testing, and reference specific FDA labeling language about the drug's role in treatment. Taking time to address each policy criterion point-by-point makes a significant difference.

Appeals Process in California

If your Signifor prior authorization is denied, California offers robust appeal rights through both UnitedHealthcare's internal process and the state's Independent Medical Review (IMR) system.

Internal Appeals with UnitedHealthcare

First Level Appeal

  • Deadline: 180 days from denial notice
  • Timeline: 30 days for standard, 72 hours for expedited
  • Submit via: Provider portal, phone, or written request
  • Required: Denial letter, additional clinical documentation, physician letter

Peer-to-Peer Review

  • Request physician-to-physician discussion
  • Available during initial PA or appeal process
  • Often resolves cases without formal appeal

California Independent Medical Review (IMR)

California's IMR process provides external review by independent medical experts and has historically shown favorable outcomes for medically necessary treatments.

Eligibility

  • Must complete UnitedHealthcare's internal appeal first
  • Denial based on medical necessity, experimental/investigational determination, or emergency services dispute
  • No cost to patients

Timeline

  • Standard IMR: 45 days from acceptance
  • Expedited IMR: 7 days or less for urgent cases
  • Emergency: 72 hours when immediate treatment needed

How to File

  1. Complete internal appeal with UnitedHealthcare
  2. File IMR application with California Department of Managed Health Care
  3. Submit all medical records and denial documentation
  4. Await independent medical expert review

Success Factors for IMR

  • Strong endocrinologist support letter
  • Clear documentation of medical necessity
  • Reference to established treatment guidelines
  • Evidence of failed alternatives (when applicable)
Note: California's new AB 510 legislation (effective October 2025) requires appeals to be reviewed by physicians of the same or similar specialty, improving fairness for rare endocrine conditions.

FAQ

How long does UnitedHealthcare prior authorization take for Signifor in California? Standard prior authorization takes up to 15 business days. Expedited review is available for urgent cases and typically completes within 72 hours. Submit requests 7-10 days before the medication is needed.

What if Signifor is non-formulary on my specific plan? Signifor is typically on UnitedHealthcare's specialty formulary tiers. If it appears non-formulary, request a formulary exception with strong clinical documentation showing medical necessity and lack of suitable alternatives.

Can I request an expedited appeal if my condition is worsening? Yes. Both UnitedHealthcare's internal appeals and California's IMR process offer expedited review for urgent medical situations. Document the urgency with clinical evidence of disease progression.

Does step therapy apply if I've already failed other treatments outside California? Step therapy requirements should recognize prior therapy failures regardless of where they occurred. Include complete documentation of previous treatments, outcomes, and reasons for discontinuation in your PA request.

What happens if UnitedHealthcare approves Signifor but my specialty pharmacy can't fill it? Contact UnitedHealthcare's specialty pharmacy network (Accredo or Optum Specialty) to resolve dispensing issues. If problems persist, file a grievance with your health plan and contact California's DMHC Help Center at 888-466-2219.

Are there financial assistance programs for Signifor in California? Yes. Check Recordati's patient support programs for copay assistance. Additionally, California has state pharmaceutical assistance programs and foundation grants available for rare disease treatments.

How do I verify my UnitedHealthcare plan's specific requirements? Log into your member portal or call member services. For the most current prior authorization requirements, providers should check the UHC Provider Portal or call 800-903-5253.

What if my endocrinologist isn't in the UnitedHealthcare network? Out-of-network specialists may still be able to prescribe Signifor, but you'll likely face higher cost-sharing. Consider requesting a network exception if no in-network endocrinologists are available in your area, especially in rural parts of California.

For patients navigating complex prior authorization requirements like those for Signifor, Counterforce Health helps turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with each payer's specific requirements, pulling the right clinical evidence and ensuring all procedural requirements are met for optimal appeal outcomes.

Sources & Further Reading

Disclaimer: This article provides educational information about insurance coverage and appeal processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and work with qualified professionals for insurance appeals. Coverage policies and procedures may change; verify current requirements with UnitedHealthcare and California regulatory agencies.

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