By Counterforce Health Team in Somatuline Depot (lanreotide) —

How to Get Somatuline Depot (Lanreotide) Covered by Blue Cross Blue Shield in Washington: Complete Prior Authorization and Appeals Guide

Quick Answer: Blue Cross Blue Shield plans in Washington (primarily Premera Blue Cross) require prior authorization for Somatuline Depot (lanreotide), typically demanding an octreotide trial first. Submit PA with specialist documentation, FDA-approved diagnosis (acromegaly, GEP-NETs, carcinoid syndrome), and clinical failure evidence. If denied, appeal within 180 days internally, then request external IRO review. Start by calling your plan's provider services to confirm current PA criteria and submission portal.

Table of Contents

Coverage Overview: BCBS Plans in Washington

In Washington state, Blue Cross Blue Shield coverage is primarily provided through Premera Blue Cross and Regence BlueShield. Both require prior authorization (PA) for Somatuline Depot (lanreotide), treating it as a specialty medication with strict utilization management.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all strengths Premera formulary documents Plan-specific
Formulary Status Listed in specialty tiers Plan formulary lookup Premera provider portal
Step Therapy Octreotide trial typically required PA criteria documents Plan policies
Quantity Limits 1-2 syringes per 28 days Custom select drug lists BCBS quantity programs
Specialist Required Endocrinologist or oncologist PA submission requirements Plan criteria
Appeals Deadline 180 days from denial notice Premera appeals process WA-specific

Somatuline Depot is typically covered under the medical benefit when provider-administered, billed using HCPCS code J1932 (lanreotide, 1 mg per unit).

FDA Indications and Medical Necessity

Somatuline Depot has three FDA-approved indications that insurers consider for coverage:

  1. Acromegaly: Long-term treatment in patients with inadequate response to surgery and/or radiotherapy
  2. Gastroenteropancreatic Neuroendocrine Tumors (GEP-NETs): Improving progression-free survival in unresectable, well- or moderately-differentiated tumors
  3. Carcinoid Syndrome: Reducing frequency of short-acting somatostatin analogue rescue therapy

Medical Necessity Documentation

Plans require specific evidence that treatment is medically necessary:

  • Confirmed diagnosis with appropriate ICD-10 codes (E22.0 for acromegaly, NET-specific codes)
  • Baseline laboratory values (GH, IGF-1 for acromegaly; chromogranin A, 5-HIAA for NETs)
  • Imaging studies (MRI for pituitary tumors, CT/MRI for NETs, octreotide scintigraphy)
  • Specialist evaluation from endocrinologist (acromegaly) or oncologist (NETs/carcinoid)
Note: Off-label uses are rarely covered without extensive documentation and may require external review for approval.

Step Therapy Requirements

Most BCBS plans in Washington require patients to try and fail octreotide before approving Somatuline Depot. This "step therapy" mandate typically includes:

Required Octreotide Trial

  • Short-acting octreotide: At least 2 weeks of subcutaneous injections
  • Sandostatin LAR: 3-6 months of monthly intramuscular injections (typically 30 mg)
  • Documentation of failure: Objective measures like persistent elevated IGF-1 levels (>300 ng/mL when normal is <220 ng/mL) or inadequate symptom control

Exceptions to Step Therapy

You can bypass the octreotide requirement with documentation of:

  • Hypersensitivity to octreotide or its components
  • Contraindications (severe gallbladder disease, certain cardiac conditions)
  • Previous intolerance with specific adverse events documented
  • Clinical urgency where delay could harm patient outcomes

When requesting step therapy exceptions, include a detailed specialist letter explaining why octreotide is inappropriate or contraindicated.

Quantity Limits and Dosing

BCBS plans align quantity limits with FDA-approved dosing:

  • Standard limit: 1 syringe per 28 days (matching every-4-weeks dosing)
  • Available strengths: 60 mg, 90 mg, and 120 mg prefilled syringes
  • Maximum dose: 120 mg every 4 weeks (higher doses require exceptional documentation)

Dosing Considerations

  • Initial dosing often starts at 90 mg every 4 weeks
  • Dose adjustments based on clinical response and lab values
  • Plans may require dose titration documentation for higher strengths

Required Documentation

Checklist: What to Gather Before Starting PA

Patient Information:

  • Insurance card and member ID
  • Complete contact information
  • Previous denial letters (if applicable)

Clinical Documentation:

  • Specialist consultation notes
  • Pathology reports (for NETs)
  • Laboratory results (baseline and monitoring)
  • Imaging studies with radiology reports
  • Previous treatment records and outcomes

Prescription Details:

  • Specific strength and dosing schedule
  • NDC number and HCPCS codes
  • Administration site and method
  • Duration of therapy requested

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify benefits through Premera provider portal or member services
  2. Gather documentation using the checklist above
  3. Submit PA request via electronic portal (preferred) or fax to 425-918-5592
  4. Include specialist letter addressing medical necessity and step therapy compliance
  5. Follow up within 3-5 business days if no response received
  6. Request peer-to-peer if initial denial to discuss clinical rationale
  7. File appeal immediately if denied, within 180-day deadline

PA Submission Requirements

Clinical Information Needed:

  • Patient demographics and insurance details
  • Primary diagnosis with ICD-10 code
  • Treatment history and prior medication failures
  • Current symptoms and functional status
  • Proposed treatment plan and monitoring schedule

Provider Information:

  • Prescriber name, NPI, and specialty certification
  • Practice address and contact information
  • DEA number (if applicable)
  • Relationship to patient and duration of care

Appeals Playbook for Washington

Washington state provides robust appeal rights through both internal insurer processes and external independent review.

Internal Appeals Process

Timeline: 180 days from denial notice to file internal appeal

Submission Methods:

  • Mail: Appeals Coordinator, Premera Blue Cross, P.O. Box 91102, Seattle, WA 98111-9202
  • Fax: 425-918-5592
  • Online: Through member or provider portal

Required Elements:

  • Original denial letter and claim number
  • Member ID and service dates
  • Complete medical records supporting medical necessity
  • Specialist letter addressing denial rationale
  • Clinical guidelines or literature supporting treatment

Decision Timelines

Appeal Type Review Time Notes
Standard post-service 30 days Written decision required
Expedited/urgent 72 hours When delay could harm health
Pre-service 15 days For prior authorization denials

External Review (IRO Process)

If internal appeals fail, Washington residents can request Independent Review Organization (IRO) review:

  • Eligibility: Medical necessity denials, experimental treatment disputes
  • Timeline: Must request after final internal denial
  • Process: Submit through Premera (they coordinate with Washington OIC)
  • Decision: Binding on insurer, typically within 60 days
  • Cost: Free to patient
Tip: Contact Washington Office of Insurance Commissioner at 800-562-6900 for assistance with appeals or to file complaints about insurer practices.

Cost Assistance Options

Manufacturer Support Programs

Ipsen Cares Patient Assistance Program:

Foundation Grants

  • Patient Access Network Foundation: NET-specific grants
  • CancerCare Co-Payment Assistance: For cancer-related treatments
  • Neuroendocrine Tumor Research Foundation: Patient assistance programs

State Resources

  • Washington Apple Health (Medicaid): Expanded coverage options
  • Washington Healthplanfinder: Marketplace plans with premium subsidies

Common Denial Reasons & How to Overturn Them

Denial Reason How to Overturn Required Documentation
No octreotide trial Provide trial records or contraindication Pharmacy records, specialist letter, allergy documentation
Off-label use Demonstrate medical necessity Peer-reviewed studies, specialty guidelines, case reports
Lack of specialist Get endocrinologist/oncologist evaluation Specialist consultation notes, board certification
Insufficient documentation Submit complete clinical records Labs, imaging, pathology, treatment history
Quantity limit exceeded Justify higher dosing Clinical trials data, dose-response studies
Not medically necessary Provide evidence-based rationale Guidelines, FDA labeling, specialist attestation

FAQ

How long does BCBS prior authorization take in Washington? Standard PA decisions typically take 15 days for pre-service requests and 30 days for post-service reviews. Expedited reviews are completed within 72 hours when clinical urgency is demonstrated.

What if Somatuline Depot is non-formulary on my plan? Non-formulary medications require formulary exception requests with enhanced documentation of medical necessity. Include evidence that preferred alternatives are inappropriate or have failed.

Can I request an expedited appeal? Yes, if delay in treatment could seriously jeopardize your health. Submit expedited appeal requests with physician documentation of clinical urgency.

Does step therapy apply if I tried octreotide in another state? Yes, previous trials from other states count toward step therapy requirements. Obtain pharmacy records and physician notes documenting the trial and failure.

What happens if my appeal is denied? After final internal denial, you can request external IRO review at no cost. The IRO decision is binding on the insurer and typically final.

How do I find my specific BCBS plan's formulary? Check your member portal, call the number on your insurance card, or visit your plan's website. Premera and Regence have separate formularies and processes.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex prior authorization and appeals processes. Our platform analyzes denial letters, identifies specific coverage criteria, and generates evidence-backed appeals that speak directly to payers' own policies. By automating the tedious work of gathering citations and formatting appeals, we help ensure patients get access to necessary medications faster.

For additional support with Somatuline Depot appeals or other specialty medication coverage challenges, visit Counterforce Health to learn how our platform can streamline your approval process.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and change frequently. Always consult your specific insurance plan documents and healthcare providers for current requirements and clinical guidance. For assistance with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 800-562-6900.

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