By Counterforce Health Team in Somatuline Depot (lanreotide) —

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

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

Fastest path to approval: Submit Aetna's prior authorization form with complete clinical documentation showing medical necessity for acromegaly or neuroendocrine tumors. No octreotide trial required. First step today: Download the Illinois-specific PA form from PrescriberPoint and gather IGF-1 labs, diagnosis codes, and treatment history. Submit electronically via Availity for fastest processing (typically 30-45 days). If denied, Illinois residents have 4 months to request external review through the Illinois Department of Insurance.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required Yes, for all Aetna plans PA form needed before coverage Aetna Precert List
Formulary Tier Tier 1-3 (varies by plan) Check member's specific formulary Plan Documents
Step Therapy No octreotide trial required Aetna clinical policy Coverage Policy
Quantity Limits 1 injection every 28 days Standard dosing schedule Quantity Limits
Specialty Pharmacy CVS Specialty required Limited distribution drug CVS Specialty
Appeals Deadline (Illinois) 4 months for external review After final denial Illinois DOI

Before You Start

Verify your plan details before submitting your prior authorization request:

  • Check if you have Aetna commercial, Medicare, or Medicaid - requirements may vary slightly
  • Confirm your prescriber is in-network with Aetna CVS Health
  • Determine benefit coverage: Somatuline Depot may be covered under medical benefit (Part B) for in-office administration or pharmacy benefit (Part D) for home injection
  • Review your formulary tier to understand expected copays
Tip: Call the member services number on your Aetna card to confirm your specific plan's coverage details and copay structure.

Step-by-Step: Fastest Path to Approval

1. Download the Correct Prior Authorization Form

Who does it: Your prescriber's office
Document needed: Illinois-specific Aetna PA form for Somatuline Depot
Timeline: Same day

2. Gather Clinical Documentation

Who does it: Patient and medical team
Documents needed: IGF-1 lab results, diagnosis confirmation, prior treatment history
Timeline: 1-3 days

3. Complete the PA Form Thoroughly

Who does it: Prescriber's office
Requirements: All fields must be completed and legible
Timeline: 1-2 days

4. Submit Electronically via Availity

How to submit: Availity portal (preferred) or fax
Expected timeline: 30-45 days for standard review
Backup: Fax to specialty PA line if electronic submission fails

5. Follow Up Weekly

Who does it: Patient or clinic staff
What to ask: "What's the status of PA request #[reference number]?"
Timeline: Weekly until decision

6. If Approved, Coordinate with CVS Specialty

Who does it: Patient
Action: Contact CVS Specialty Pharmacy to arrange delivery
Timeline: 3-5 business days for first shipment

7. If Denied, Request Peer-to-Peer Review

Who does it: Prescriber
Action: Call Aetna to request discussion with medical director
Timeline: Within 14 days of denial

Gather What You Need

For Acromegaly Patients:

  • High IGF-1 lab results for age/gender
  • Documentation of inadequate response to surgery/radiotherapy OR clinical reason surgery/radiotherapy wasn't appropriate
  • Current symptoms and functional status
  • ICD-10 code: E22.0 (Acromegaly and pituitary gigantism)

For GEP-NET/Carcinoid Patients:

  • Confirmed neuroendocrine tumor diagnosis
  • Tumor location (GI tract, pancreas, lungs, or thymus)
  • Imaging studies showing tumor burden
  • Symptom documentation (if carcinoid syndrome present)
  • ICD-10 codes: C25.4 (Pancreatic NET), C78.00 (Carcinoid), others as appropriate

Universal Requirements:

  • Complete medication history
  • Allergy/intolerance documentation
  • Insurance card and member ID
  • Prescriber NPI and contact information

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Submit peer-reviewed evidence and guidelines FDA labeling, endocrine society guidelines
"Non-formulary" Request formulary exception Clinical rationale letter, alternative drug failures
"Quantity limit exceeded" Submit exception request Quantity limit exception form with medical justification
"Experimental/investigational" Provide FDA approval documentation FDA labeling for approved indications

Appeals Playbook for Aetna CVS Health in Illinois

Level 1: Internal Appeal

  • Timeline: Submit within 180 days of denial
  • Decision time: 30-45 days (standard), 72 hours (expedited)
  • How to file: Call member services or submit written appeal
  • Required: Patient consent, additional clinical evidence

Level 2: Peer-to-Peer Review

  • Who can request: Prescribing physician only
  • Timeline: Request within 14 days of denial
  • Process: Phone discussion with Aetna medical director
  • Contact: Aetna Provider Services

Level 3: External Review (Illinois)

  • Eligibility: After exhausting internal appeals, costs >$500
  • Timeline: Request within 4 months of final denial
  • Decision time: 30 days (5 days expedited)
  • How to file: Illinois Department of Insurance form
  • Cost: Free to patient
Note: Illinois external review decisions are binding on Aetna CVS Health.

Patient Phone Scripts

Calling Aetna Member Services

"Hi, I'm calling to check the status of a prior authorization request for Somatuline Depot. My member ID is [ID number]. The PA was submitted on [date] by Dr. [name]. Can you tell me the current status and reference number?"

If approved: "When will my pharmacy be notified? Do I need to contact CVS Specialty directly?"

If pending: "What additional information is needed? What's the expected decision timeline?"

If denied: "Can you transfer me to someone who can help me understand the denial reason and appeal options?"

Requesting Expedited Review

"My doctor says this medication is urgent for my condition. How do I request an expedited review? What documentation do you need from my physician?"

Costs & Savings Options

Manufacturer Support:

Foundation Grants:

  • Patient Access Network Foundation
  • The Assistance Fund
  • CancerCare Co-Payment Assistance Foundation

State Resources:

  • Illinois Medicaid expansion covers many low-income adults
  • Contact Illinois Department of Human Services for eligibility
Important: Copay assistance may not be available for Medicare patients due to federal regulations.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform identifies the specific denial basis and drafts point-by-point responses aligned to each payer's own rules, helping patients, clinicians, and specialty pharmacies get prescription drugs approved more efficiently.

FAQ

How long does Aetna CVS Health prior authorization take in Illinois? Standard reviews take 30-45 days. Expedited reviews (when urgent) are completed within 72 hours. Submit requests at least two weeks before planned treatment.

What if Somatuline Depot is non-formulary on my plan? You can request a formulary exception by providing clinical documentation showing medical necessity and why formulary alternatives aren't appropriate.

Can I request an expedited appeal if my health is at risk? Yes. Illinois law requires expedited external reviews within 24-72 hours when delays would seriously jeopardize your health. Your physician must certify the urgency.

Does step therapy apply if I've tried octreotide outside Illinois? Aetna doesn't require octreotide trials before Somatuline Depot approval. Previous trials from other states should be documented but aren't mandatory.

What happens if my appeal is denied? You can request external review through the Illinois Department of Insurance within 4 months. This independent physician review is binding on Aetna.

How do I find CVS Specialty Pharmacy contact information? Call the number on your Aetna card or visit Aetna's specialty pharmacy page for direct contact information.

When to Escalate

Contact the Illinois Department of Insurance if:

  • Aetna doesn't respond within required timeframes
  • You need help understanding your appeal rights
  • You want to file a complaint about claim handling

Contact Information:

  • Phone: 877-527-9431
  • Website: idoi.illinois.gov
  • Office of Consumer Health Insurance assistance available

Illinois Attorney General Health Care Helpline:

  • Phone: 877-305-5145
  • Can intervene informally with insurers
  • Assists with complex appeal cases

For patients navigating complex prior authorization requirements, Counterforce Health provides comprehensive support by analyzing insurance policies, identifying denial patterns, and creating evidence-based appeals that significantly improve approval rates for specialty medications like Somatuline Depot.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance company directly for coverage determinations. Coverage policies and requirements may change; verify current information with Aetna CVS Health and Illinois regulators.

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