By Counterforce Health Team in Somatuline Depot (lanreotide) —

How to Get Somatuline Depot (Lanreotide) Covered by Cigna in Ohio: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Somatuline Depot Covered by Cigna in Ohio

Cigna requires prior authorization for Somatuline Depot (lanreotide), typically places it on Tier 4/5 specialty formulary, and mandates step therapy with octreotide (Sandostatin LAR) first. In Ohio, if denied, you have 180 days to appeal internally, then 180 days for external review through the Ohio Department of Insurance.

First steps: 1) Verify your plan type (HMO needs specialist referral, PPO/EPO don't), 2) Have your endocrinologist/oncologist submit Cigna's Somatuline Depot prior authorization form with step therapy documentation, 3) Enroll with Accredo specialty pharmacy for dispensing.

Table of Contents

Plan Types & Referral Requirements

Your Cigna plan type determines whether you need a referral to see the specialist who'll prescribe Somatuline Depot:

HMO (Health Maintenance Organization):

  • Referral required from your primary care provider (PCP) to see an endocrinologist or oncologist
  • Must use in-network specialists only
  • Contact your PCP first to request a specialist referral

PPO (Preferred Provider Organization):

  • No referral needed - schedule directly with any in-network specialist
  • Out-of-network options available (higher cost-sharing)

EPO (Exclusive Provider Organization):

  • No referral needed for in-network specialists
  • Out-of-network care not covered except emergencies
Note: Even without referral requirements, the specialist must still obtain prior authorization for Somatuline Depot regardless of your plan type.

Check your member ID card or Cigna's plan comparison tool to confirm your plan type.

Formulary Status & Tier Placement

Somatuline Depot (lanreotide) is consistently placed on Tier 4 or Tier 5 (Specialty) across Cigna's formularies, making it one of the most expensive medication tiers.

Coverage at a Glance

Requirement Details Where to Find It Source
Prior Authorization Yes, required for all indications Cigna provider portal PA Form
Formulary Tier Tier 4-5 (Specialty) Plan formulary document Medicare Formulary
Step Therapy Octreotide (Sandostatin LAR) trial required Coverage policy Non-oncology Policy
Quantity Limits Typically 1 syringe per 28 days Plan documents Contact Cigna directly
Specialty Pharmacy Accredo required Member portal Express Scripts/Accredo
Prescriber Requirement Endocrinologist or oncologist Coverage criteria PA Form requirements

Prior Authorization & Step Therapy Rules

Cigna's prior authorization process for Somatuline Depot involves strict clinical criteria and documentation requirements.

Step Therapy Requirements

Before approving Somatuline Depot, Cigna typically requires:

  1. Trial of octreotide (Sandostatin LAR) with documented:
    • Inadequate response after appropriate trial period
    • Intolerable side effects
    • Medical contraindication to octreotide
  2. Clinical documentation including:
    • Confirmed diagnosis (acromegaly, gastroenteropancreatic neuroendocrine tumors, carcinoid syndrome)
    • Relevant lab values and imaging
    • Treatment history and outcomes
  3. Specialist prescriber (endocrinologist for acromegaly, oncologist for NETs)

Medical Necessity Criteria

According to Cigna's coverage policy, approval requires:

  • Acromegaly: Failed surgical intervention or not a surgical candidate, plus octreotide trial
  • GEP-NETs: Histologically confirmed diagnosis with appropriate staging
  • Carcinoid syndrome: Documented symptoms with biochemical confirmation

Specialty Pharmacy Requirements

Somatuline Depot must be dispensed through Cigna's preferred specialty pharmacy network, primarily Accredo (Express Scripts specialty division).

Enrollment Process

  1. Prescription routing: Your doctor sends the prescription to Accredo, not your local pharmacy
  2. Patient enrollment: Accredo contacts you to set up delivery and administration scheduling
  3. Site of care: Must be administered by healthcare professionals - typically at your doctor's office or infusion center
  4. Coordination: Accredo coordinates with your healthcare provider for delivery timing
Tip: Enroll with Accredo as soon as your doctor submits the prescription to avoid delays. Call 1-800-803-2523 to check enrollment status.

Cost-Share Dynamics

As a Tier 4/5 specialty medication, Somatuline Depot carries significant out-of-pocket costs:

  • Typical coinsurance: 20-40% of drug cost
  • Monthly cost range: $1,500-$3,700+ per injection (varies by strength and plan)
  • Deductible impact: May need to meet specialty drug deductible first

Cost Factors

  • Your specific plan's specialty tier cost-sharing
  • Whether you've met your annual deductible
  • Availability of manufacturer assistance programs

Step-by-Step: Fastest Path to Approval

For Patients:

  1. Verify plan type and network status of your specialist (call member services if unsure)
  2. Obtain referral if needed (HMO plans only - contact your PCP)
  3. Schedule with appropriate specialist (endocrinologist for acromegaly, oncologist for NETs)
  4. Gather prior treatment records showing octreotide trial/failure or contraindication
  5. Confirm specialist will handle PA submission and provide timeline expectations

For Clinicians:

  1. Complete prior authorization form using Cigna's Somatuline Depot PA form
  2. Document step therapy compliance with detailed octreotide trial history
  3. Include comprehensive clinical notes with diagnosis, labs, imaging, treatment goals
  4. Submit via Cigna provider portal or fax (verify current submission method)
  5. Follow up within 5-7 business days if no initial response
  6. Request peer-to-peer review if denied to discuss case with Cigna medical director

Expected timeline: 7-14 business days for standard review, 72 hours for expedited (if urgency documented).

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
No octreotide trial Submit step therapy exception Medical contraindication letter, allergy documentation, or prior failure records
Insufficient clinical info Resubmit with complete records Lab results, imaging, specialist consultation notes
Non-specialist prescriber Transfer to appropriate specialist Endocrinology or oncology consultation
Off-label use Provide evidence-based justification Published guidelines, FDA label language, peer-reviewed studies
Quantity limit exceeded Medical necessity override Dosing rationale, clinical response data, guideline support

Appeals Process in Ohio

If your Somatuline Depot prior authorization is denied, Ohio provides a structured appeals pathway with binding external review.

Internal Appeals (with Cigna)

  • Timeline: File within 180 days of denial notice
  • Decision timeframe: 30 days for standard, 72 hours for expedited
  • Required: Submit via Cigna appeals process with supporting clinical documentation

Ohio External Review

After exhausting internal appeals:

  • Timeline: Request within 180 days of final Cigna denial
  • Process: Independent Review Organization (IRO) conducts binding review
  • Contact: Ohio Department of Insurance Consumer Services: 1-800-686-1526
  • Forms: Available at Ohio Department of Insurance website
  • Decision: Typically within 30 days (72 hours if expedited)
Note: External review decisions are binding on Cigna - if overturned, they must provide coverage.

From our advocates: "We've seen Ohio external reviews succeed when the appeal includes both the original PA denial letter and a detailed rebuttal addressing each specific denial point with clinical evidence. The IRO reviewers particularly value specialist letters that reference published treatment guidelines and explain why the standard step therapy approach isn't appropriate for the individual patient."

Clinician Corner: Medical Necessity Documentation

Essential Components for Strong PA Submissions:

Clinical History:

  • Confirmed diagnosis with ICD-10 codes
  • Relevant lab values (IGF-1, growth hormone, chromogranin A, 5-HIAA as appropriate)
  • Imaging results supporting diagnosis
  • Symptom documentation and functional impact

Prior Treatment Documentation:

  • Specific octreotide formulation, dose, duration tried
  • Clinical response or lack thereof with objective measures
  • Side effects experienced with dates and severity
  • Reasons for discontinuation or contraindication

Treatment Rationale:

  • Why Somatuline Depot is medically necessary for this patient
  • Expected clinical outcomes and monitoring plan
  • Reference to relevant treatment guidelines (Endocrine Society, NCCN as applicable)

Key Guidelines to Reference:

  • Acromegaly: Endocrine Society Clinical Practice Guidelines
  • NETs: NCCN Guidelines for Neuroendocrine and Adrenal Tumors
  • FDA labeling: Official prescribing information for approved indications

Costs & Patient Assistance Programs

Manufacturer Support

IPSEN CARES Program offers copay assistance for commercially insured patients:

  • May reduce copay to $0 for eligible patients
  • Does not apply to Medicare or Medicaid
  • Contact: 1-844-447-7362 or ipsen.com/us/patients

Additional Resources

  • Patient Access Network Foundation: Assistance for neuroendocrine tumor patients
  • HealthWell Foundation: Copay assistance programs
  • State pharmaceutical assistance programs: Contact Ohio Department of Commerce for state-specific options
Important: Verify eligibility requirements and program availability, as these can change.

FAQ

How long does Cigna prior authorization take for Somatuline Depot in Ohio? Standard review: 7-14 business days. Expedited review (with documented urgency): 72 hours. Timeline starts when Cigna receives complete documentation.

What if Somatuline Depot isn't on my Cigna formulary? Submit a formulary exception request with your PA. Include clinical justification for why preferred alternatives aren't appropriate.

Can I get expedited review in Ohio? Yes, if your doctor documents that delay would seriously jeopardize your health. Submit expedited PA request with clinical urgency justification.

Does step therapy apply if I failed octreotide outside Ohio? Yes, prior treatment history from any location counts. Ensure your new Ohio provider has complete records of your octreotide trial.

What if my appeal is denied by Cigna? Request external review through Ohio Department of Insurance within 180 days. The IRO decision is binding on Cigna.

How do I find Cigna specialists in Ohio? Use Cigna's provider directory and filter by specialty (endocrinology/oncology) and Ohio location.

When to Contact Ohio Regulators

Contact the Ohio Department of Insurance if:

  • Cigna refuses to accept your appeal
  • You experience unreasonable delays in the review process
  • You need help understanding your external review rights
  • You want to file a complaint about claims handling

Contact: 1-800-686-1526 or insurance.ohio.gov

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our 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 procedural documentation to maximize approval chances.

Getting Somatuline Depot covered by Cigna in Ohio requires navigating multiple layers of utilization management, but with proper documentation and persistence through the appeals process, many patients ultimately receive coverage. The key is understanding Cigna's specific requirements, preparing comprehensive clinical justification, and knowing your rights under Ohio's external review process.

For additional support navigating your specific situation, Counterforce Health can help analyze your denial and develop a targeted appeal strategy based on your plan's exact coverage criteria.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies can change, and individual circumstances vary. Always verify current requirements with Cigna directly and consult with your healthcare provider regarding treatment decisions. For personalized assistance with appeals and prior authorizations, consider consulting with patient advocacy services or legal professionals specializing in healthcare coverage.

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