By Counterforce Health Team in Somatuline Depot (lanreotide) —

How to Get Somatuline Depot (Lanreotide) Covered by Aetna CVS Health in Florida: Complete Prior Authorization Guide

Answer Box: Getting Somatuline Depot Covered by Aetna CVS Health in Florida

Fastest path to approval: Submit Aetna's Somatuline Depot Precertification Request form (GR-69561) with complete clinical documentation showing medical necessity for acromegaly, GEP-NETs, or carcinoid syndrome. Use the Availity provider portal for fastest processing (72-hour decisions vs. 30+ days by mail). First step today: Verify your specific Aetna plan covers specialty drugs and gather IGF-1 lab results, diagnosis codes, and documentation of any failed prior treatments. If denied, Florida law gives you 180 days to appeal with external review options through the Florida Department of Financial Services.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Aetna plans 2024 Precertification List Aetna
Formulary Status Covered with PA Aetna Drug Guide Aetna
Quantity Limits One syringe per 28 days Specialty Quantity Limits Aetna
Step Therapy May require octreotide trial first Somatostatin Analogue Policy Aetna
Appeal Deadline 180 days from denial Florida Insurance Law FL DFS

Step-by-Step: Fastest Path to Approval

1. Verify Plan Coverage (Patient/Clinic)

  • Action: Check if your specific Aetna plan includes specialty drug coverage
  • Document: Insurance card and Summary of Benefits
  • Timeline: Same day
  • Source: Aetna Member Services

2. Gather Clinical Documentation (Clinic)

  • Action: Collect IGF-1 lab results, diagnosis codes, and prior treatment records
  • Documents: Lab reports, chart notes, previous medication trials
  • Timeline: 1-3 days
  • Source: PA Requirements

3. Complete PA Form (Provider)

  • Action: Submit Somatuline Depot Precertification Request (GR-69561)
  • Portal: Availity provider portal (preferred)
  • Timeline: 72 hours for decision
  • Alternative: Fax to 1-888-267-3277

4. CVS Specialty Enrollment (Patient/Clinic)

  • Action: Transfer prescription to CVS Caremark Specialty
  • Process: CVS transfer portal or call during PA review
  • Timeline: 2-5 business days
  • Source: CVS Caremark

5. Monitor Decision (Patient/Clinic)

  • Action: Check approval status via provider portal or member services
  • Contact: 1-866-752-7021 for status updates
  • Timeline: 72 hours (expedited) or 30 days (standard)

6. Appeal if Denied (Patient/Provider)

  • Action: File internal appeal within 180 days
  • Forms: Aetna Appeals Process
  • Timeline: 30 days for standard, 72 hours for expedited
  • Source: Florida Insurance Law

7. External Review (Patient)

Forms and Documentation

Primary Form

The Somatuline Depot Precertification Request (GR-69561) is required for all requests. Submit at least two weeks before needed treatment date.

Required Clinical Documentation

  • Laboratory reports documenting the patient's condition
  • Evidence of treatment failures with alternatives like Sandostatin or Sandostatin LAR
  • Diagnosis information with appropriate ICD-10 codes
  • Site of care specifications (office, infusion center, or home administration)
Clinician Corner: For acromegaly, document high pretreatment IGF-1 levels and inadequate surgical/radiation response. For GEP-NETs, include pathology confirming well- or moderately-differentiated tumors and staging showing unresectable disease. Reference FDA labeling and NCCN guidelines in your medical necessity letter.

Submission Portals and Methods

Electronic Submission (Fastest)

  • Portal: Availity provider website
  • Decision time: 72 hours for non-urgent requests
  • Benefits: Automated status tracking and faster processing

Alternative Methods

  • Fax: 1-888-267-3277
  • Phone: 1-866-752-7021 (TTY: 711)
  • Processing time: Up to 30 days

CVS Caremark Electronic PA

CVS Caremark offers accelerated electronic prior authorization through EHR integration, which can significantly speed up the review process.

Specialty Pharmacy Enrollment

Most Aetna plans require Somatuline Depot to be dispensed through CVS Caremark Specialty Pharmacy. Here's how to enroll:

Transfer Process

  1. Gather information: Current prescription label and patient details
  2. Use CVS transfer portal: Visit cvs.com/transfer
  3. Complete three steps: Enter patient info, current pharmacy info, and choose CVS location
  4. Timeline: 2-5 business days for transfer completion

Required Information

  • Current prescription label
  • Patient insurance information
  • Prescriber contact details
  • Preferred delivery address
Note: You can initiate transfers through the CVS mobile app anytime, making the process more convenient for patients.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Non-formulary status Request formulary exception Medical necessity letter, clinical guidelines
Step therapy requirement Document octreotide failure/intolerance Treatment records, adverse event documentation
Quantity limit exceeded Justify medical necessity for dosing Weight-based calculations, specialist recommendation
Off-label use Provide evidence base Peer-reviewed studies, compendia references
Lack of specialist Obtain endocrinologist/oncologist consultation Specialist evaluation and recommendation

Appeals Process in Florida

Internal Appeals

  • Deadline: 180 days from denial notice
  • Standard timeline: 30 calendar days for decision
  • Expedited timeline: 72 hours if delay could jeopardize health
  • Submission: Aetna appeals portal or fax

External Review

Florida provides independent external review through the Department of Financial Services. This process:

  • Must be requested within 4 months of final internal denial
  • Is free to consumers
  • Results in binding decisions if reviewer overturns denial
  • Can be expedited for urgent cases (72-hour decisions)

Required Appeal Documentation

  • Original denial letter
  • Complete medical records (minimum 6 months)
  • Physician's medical necessity statement
  • Clinical guidelines supporting treatment
  • Documentation of failed alternative treatments
From our advocates: We've seen successful appeals when providers include specific language from Aetna's own medical policy showing how the patient meets coverage criteria. Reference the exact policy number and cite the specific clinical requirements that are satisfied in your case.

Support Lines and Contacts

For Patients

  • Aetna Member Services: 1-866-752-7021 (TTY: 711)
  • CVS Caremark: Contact through member portal or prescription bottle
  • Florida Insurance Consumer Helpline: 1-877-MY-FL-CFO (1-877-693-5236)

For Providers

What to Ask When Calling

  • Specific reason for denial with policy reference
  • Required documentation for approval
  • Timeline for resubmission
  • Appeal rights and deadlines
  • Case reference number for tracking

When to Contact Florida Regulators

Contact the Florida Department of Financial Services if:

  • Aetna doesn't respond within required timeframes
  • You believe the denial violates Florida insurance law
  • Internal appeals are repeatedly denied without clear justification
  • You need assistance navigating the external review process

Contact methods:

  • Phone: 1-877-MY-FL-CFO (1-877-693-5236)
  • Online complaint: apps.fldfs.com
  • Response requirement: Insurance companies must respond within 14 days

The DFS also offers mediation services as an alternative dispute resolution option before pursuing legal action.

FAQ

How long does Aetna CVS Health prior authorization take for Somatuline Depot in Florida? Standard decisions take up to 30 days, but electronic submissions through the Availity portal receive decisions within 72 hours. Source: Aetna PA policy

What if Somatuline Depot is non-formulary on my Aetna plan? You can request a formulary exception by demonstrating medical necessity. Include clinical evidence showing why formulary alternatives are inappropriate for your condition.

Does step therapy apply if I've tried octreotide outside Florida? Yes, Aetna recognizes prior treatment failures regardless of where they occurred. Ensure your provider documents the specific reasons for octreotide discontinuation.

Can I request an expedited appeal in Florida? Yes, if the delay could seriously jeopardize your health or cause severe pain. Expedited appeals receive decisions within 72 hours.

What happens if my appeal is denied? You can request external review through the Florida Department of Financial Services. This independent review is free and results in binding decisions.

How much does Somatuline Depot cost without insurance? The medication costs $7,928–$9,348 per syringe depending on strength. Manufacturer patient assistance programs may be available through Ipsen Cares.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed documentation. Our platform identifies denial reasons and drafts point-by-point rebuttals using the right clinical evidence and procedural requirements for each payer.

When navigating complex prior authorizations like Somatuline Depot coverage, having the right documentation and following proper procedures is crucial. Counterforce Health specializes in creating appeals that meet payer-specific requirements and improve approval rates for specialty medications.

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 terms and medical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For assistance with insurance complaints in Florida, contact the Department of Financial Services at 1-877-MY-FL-CFO.

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