By Counterforce Health Team in Somatuline Depot (lanreotide) —

How to Get Somatuline Depot (Lanreotide) Covered by Cigna in New York: Complete Prior Authorization & Appeals Guide

Answer Box: Getting Somatuline Depot Covered by Cigna in New York

Eligibility: Somatuline Depot requires prior authorization from Cigna for acromegaly, gastroenteropancreatic neuroendocrine tumors (GEP-NET), and carcinoid syndrome. Fastest approval path: Have your endocrinologist or oncologist submit a complete PA request through Express Scripts' electronic system with documented octreotide trial failure (if required) and specialty consultation. First step today: Call Cigna at 1-800-244-6224 to verify your plan's specific step therapy requirements and confirm whether you need specialty pharmacy enrollment. New York's external appeal protections give you strong backup options if initially denied.

Table of Contents

  1. Why New York State Rules Matter
  2. Cigna's Prior Authorization Requirements
  3. Step Therapy Protections in New York
  4. Turnaround Times and Deadlines
  5. Appeals Process: Internal to External Review
  6. Common Denial Reasons & Solutions
  7. Practical Scripts and Templates
  8. Cost Assistance and Patient Support
  9. When to Contact State Regulators
  10. FAQ

Why New York State Rules Matter

New York's robust insurance regulations provide significant protections for patients seeking specialty drug coverage like Somatuline Depot. Unlike many states, New York requires health plans to meet strict timelines for prior authorization decisions and offers one of the nation's most comprehensive external appeal systems through the Department of Financial Services.

Key New York advantages:

  • Binding external appeals with independent medical review
  • No patient fees for external appeals (as of 2025)
  • Expedited review for urgent cases (24-72 hours)
  • Strong step therapy override protections under Insurance Law Section 4903

These state protections apply to most commercial plans, though self-funded employer plans (ERISA) may have different procedures while still following federal guidelines.

Cigna's Prior Authorization Requirements

Somatuline Depot (lanreotide) is typically managed through Express Scripts, Cigna's pharmacy benefit manager, and requires prior authorization for all covered indications.

Coverage at a Glance

Requirement Details Where to Verify
Prior Authorization Required for all strengths Express Scripts PA lookup
Formulary Status Specialty tier (varies by plan) Cigna member portal
Step Therapy Often requires octreotide LAR trial Plan-specific policy
Quantity Limits One syringe per 28 days Express Scripts guidelines
Specialty Pharmacy Required (Accredo or approved network) Cigna specialty pharmacy network
Provider Requirements Endocrinologist or oncologist Medical policy

Medical Necessity Criteria

Your doctor must document:

  • Confirmed diagnosis with appropriate ICD-10 codes (E22.0 for acromegaly, C25.4 for pancreatic NET)
  • Specialist consultation (endocrinology for acromegaly, oncology for NET)
  • Prior therapy trials and outcomes (particularly octreotide if required)
  • Clinical response goals and monitoring plan
  • Contraindications to alternative therapies (if applicable)

Step Therapy Protections in New York

New York Insurance Law Section 4903 provides strong protections when insurers require you to try other medications before approving Somatuline Depot.

Override Criteria

Your healthcare provider can request a step therapy override if:

  • The required drug is contraindicated or will likely cause adverse reactions
  • The required drug is expected to be ineffective based on your clinical history
  • You've already tried the step therapy drug without success

Timeline Requirements

Health plans must decide step therapy override requests within:

  • 72 hours for standard requests
  • 24 hours for expedited/urgent requests
Tip: If Cigna fails to meet these deadlines, the override is automatically granted under New York law.

Turnaround Times and Deadlines

Understanding Cigna's response timelines helps you plan and know when to escalate.

Standard Processing

  • Express Scripts PA: Most decisions within 2 business days of complete submission
  • Cigna standard: Up to 5 business days
  • Electronic submissions: Often decided within hours through ePA systems

Expedited Processing

For urgent medical needs:

  • 24-48 hours for expedited requests
  • Call 1-800-244-6224 to request expedited review
  • Your doctor must document medical urgency

Counterforce Health helps patients and providers streamline these submissions by automatically generating evidence-backed appeals that align with payer-specific requirements, reducing back-and-forth and improving approval rates.

Appeals Process: Internal to External Review

Internal Appeals (First Level)

Timeline: 30 calendar days for standard appeals, 72 hours for urgent cases

How to file:

  1. Call Cigna member services: 1-800-244-6224
  2. Submit written appeal via member portal
  3. Include denial letter, medical records, and physician support letter

External Review (New York DFS)

If your internal appeal is denied, New York's external review system provides independent medical evaluation.

Key benefits:

  • Independent medical experts review your case
  • Binding decisions on the insurer
  • No cost to patients (fees eliminated in 2025)
  • Searchable database of prior decisions at DFS External Appeals Database

Filing process:

  • Deadline: 4 months from internal appeal denial
  • Fax: (800) 332-2729
  • Mail: NYS Department of Financial Services, Box 177, 99 Washington Avenue, Albany, NY 12210
  • Phone: 1-800-400-8882 for applications

Getting Help

Community Health Advocates provides free assistance at 888-614-5400. They can help with both internal appeals and external review filings, with approximately 50% of patient appeals succeeding in New York.

Common Denial Reasons & Solutions

Denial Reason Solution Strategy
"Not medically necessary" Submit specialty consultation notes, treatment guidelines, and documented symptom control needs
"Step therapy required" File step therapy override with contraindication or failure documentation
"Non-formulary" Request formulary exception with comparative effectiveness data
"Quantity exceeded" Provide dosing rationale and body surface area calculations if applicable
"No specialist consultation" Obtain endocrinology (acromegaly) or oncology (NET) evaluation
From our advocates: In our experience helping patients with Somatuline appeals, the most successful cases include both objective clinical data (hormone levels, imaging) and subjective quality-of-life documentation. Plans often approve when they see comprehensive specialist evaluation combined with clear treatment goals and monitoring plans.

Practical Scripts and Templates

Patient Phone Script for Cigna

"Hi, I'm calling about prior authorization for Somatuline Depot, NDC [insert NDC]. My doctor says I need this for [acromegaly/NET], and I want to understand your plan's specific requirements. Can you tell me: Do you require step therapy with octreotide first? Do I need specialty pharmacy enrollment? What's the typical turnaround time?"

Medical Necessity Letter Checklist

Your doctor should include:

  • Diagnosis confirmation with supporting lab values or imaging
  • Prior treatment history including doses, duration, and outcomes
  • Clinical rationale for Somatuline Depot specifically
  • Guideline references (FDA labeling, NCCN guidelines, Endocrine Society recommendations)
  • Monitoring plan and treatment goals
  • Contraindications to alternatives (if applicable)

Cost Assistance and Patient Support

Manufacturer Support

  • Ipsen Cares Patient Support Program: Provides copay assistance and insurance navigation
  • Income-based assistance available for eligible patients
  • Contact: Ipsen Cares program details (verify current offerings)

State and Federal Programs

  • New York Medicaid: Covers Somatuline Depot with prior authorization
  • Medicare Part D: Coverage varies by plan formulary
  • 340B programs: Available at qualified healthcare facilities

When to Contact State Regulators

Contact the New York Department of Financial Services if:

  • Cigna misses appeal deadlines
  • You're denied access to external review
  • The plan doesn't follow New York's step therapy override rules
  • You experience unfair claims practices

Consumer Complaint Hotline: 1-800-342-3736

FAQ

Q: How long does Cigna prior authorization take for Somatuline Depot in New York? A: Express Scripts typically decides within 2 business days of receiving complete documentation. Expedited requests for urgent cases can be processed within 24-48 hours.

Q: What if Somatuline Depot isn't on my Cigna formulary? A: You can request a formulary exception. Your doctor must demonstrate medical necessity and provide comparative effectiveness information showing why formulary alternatives aren't appropriate.

Q: Does step therapy apply if I was stable on Somatuline Depot with a previous insurer? A: New York's continuity of care protections may apply. You may be able to continue your current therapy for 90 days while working on authorization, especially if you're receiving ongoing treatment for a complex condition.

Q: Can I request an expedited appeal in New York? A: Yes. Both internal appeals (72 hours) and external appeals (24-72 hours) can be expedited if treatment delays would seriously jeopardize your health.

Q: What's the success rate for Somatuline Depot appeals in New York? A: While specific drug statistics aren't published, approximately 50% of patient appeals succeed in New York's system. Success rates are higher when appeals include comprehensive medical documentation and specialist support.

Q: How does ERISA affect my appeal rights? A: Self-funded employer plans follow federal ERISA rules rather than state insurance laws. However, you still have internal and external appeal rights, though the external review may be through a different entity than New York DFS.

Clinician Corner: Medical Necessity Documentation

Healthcare providers should emphasize these key elements in Somatuline Depot prior authorization requests:

For Acromegaly:

  • IGF-1 and GH levels pre- and post-surgical intervention
  • Symptomatic control needs (headaches, joint pain, sleep apnea)
  • Contraindications to surgery or surgical failure
  • FDA prescribing information supporting long-acting somatostatin analog use

For Neuroendocrine Tumors:

  • Histologic confirmation with Ki-67 index
  • Chromogranin A and 5-HIAA levels
  • Functional imaging (octreotide scan, DOTATATE PET)
  • Carcinoid syndrome symptom documentation

For All Indications:

  • Specialist consultation notes (endocrinology or oncology)
  • Treatment goal definition and monitoring plan
  • Prior therapy documentation with specific outcomes

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 your insurance plan directly for coverage determinations.

Need personalized help with your Somatuline Depot appeal? Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed submissions that align with each payer's specific requirements and policies.

Sources & Further Reading

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