By Counterforce Health Team in Somatuline Depot (lanreotide) —

How to Get Somatuline Depot (Lanreotide) Covered by Humana in Illinois: Complete Guide to Prior Authorization, Appeals, and Forms

Answer Box: Quick Start Guide

Somatuline Depot (lanreotide) requires prior authorization from Humana in Illinois. Your fastest path to approval: 1) Verify your diagnosis meets Humana's criteria (acromegaly, GEP-NETs, or carcinoid syndrome), 2) Submit the prior authorization request through Humana's provider portal or fax to 1-888-447-3430, and 3) Include medical necessity documentation from your endocrinologist or oncologist. Start today by calling Humana Member Services at 800-457-4708 to confirm your plan's specific requirements and get the current PA form.

Table of Contents

  1. Start Here: Verify Your Plan and Coverage
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Upload Instructions
  4. Fax and Mail Addresses
  5. Specialty Pharmacy Network
  6. Support Phone Numbers
  7. Illinois Appeals Process and State Resources
  8. Common Denial Reasons and Solutions
  9. FAQ

Start Here: Verify Your Plan and Coverage

Before requesting Somatuline Depot (lanreotide) coverage, confirm your specific Humana plan type and formulary status. Humana requires prior authorization for Somatuline Depot across all lines of business, including Medicare Advantage and Part D plans, effective January 1, 2024.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Humana plans Humana PA Lists Official PA list
Formulary Status May vary by plan tier Check your plan's drug guide Plan documents
HCPCS Code J1930 for billing Use for claims submission Humana billing guide
Quantity Limits Typically 30-day supply One syringe per 28 days Plan-specific

First step: Call the number on your Humana member ID card or 800-457-4708 to verify your exact coverage and get plan-specific forms.

Prior Authorization Forms and Requirements

Humana uses specific prior authorization forms for Somatuline Depot based on your plan type. The medication is approved for three main conditions:

Medical Necessity Criteria

For Acromegaly: Documentation must show diagnosis of acromegaly and evidence of inadequate response to or inability to undergo surgery/radiation therapy.

For GEP-NETs: Diagnosis of unresectable, well- or moderately-differentiated, locally advanced, or metastatic gastroenteropancreatic neuroendocrine tumors.

For Carcinoid Syndrome: Documentation of functional symptoms requiring somatostatin analog therapy.

Clinician Corner: Your medical necessity letter should include: confirmed diagnosis with ICD-10 codes, previous treatment attempts and outcomes, clinical rationale citing FDA-approved indications, planned dosing schedule, and monitoring plan. Reference the Humana clinical policy for specific documentation requirements.

Required Documentation Checklist

  • Completed Humana prior authorization form
  • Prescriber attestation letter
  • Relevant lab results and imaging
  • Documentation of prior therapy trials (if applicable)
  • Current clinical notes supporting diagnosis
  • Patient weight and body surface area (for dosing)

Submission Portals and Upload Instructions

Primary Portal: Submit through the Availity portal via Humana's provider site. Select "Log in to Availity" to access the prior authorization section.

Alternative: Use CoverMyMeds for pharmacy-related prior authorizations.

Specialty Portal: Humana PromptPA offers a standalone prior authorization portal specifically for drug requests.

Upload Requirements

  • PDF format preferred for all documents
  • Maximum file size: 10MB per document
  • Include patient name and date on all pages
  • Ensure all text is legible before uploading
Tip: Save confirmation numbers from online submissions and monitor status through the portal. Most providers receive automated updates on approval or denial decisions.

Fax and Mail Addresses

Fax Submission

Professionally Administered Drugs: 1-888-447-3430

Self-Administered Specialty Medications (Medicare): 877-486-2621

Cover Sheet Requirements: Include patient name, Humana ID number, prescriber information, and drug name clearly at the top of your fax.

Mail Submission

Check your specific Humana plan documents for the correct mailing address, as these vary by region and plan type. Always use certified mail for important submissions and retain tracking information.

Specialty Pharmacy Network

Somatuline Depot is classified as a specialty drug and must be dispensed through Humana's authorized specialty pharmacy network. The medication is typically shipped directly to your provider's office for administration.

Network Pharmacies

CenterWell Specialty Pharmacy (Humana's own specialty pharmacy) is often the primary option. Contact them directly for coordination once your prior authorization is approved.

Onboarding Steps

  1. Humana assigns a specialty pharmacy after PA approval
  2. The pharmacy contacts your provider to coordinate delivery
  3. Medication is shipped with cold-chain handling to maintain stability
  4. Provider administers the injection per the prescribed schedule

For pharmacy assignment questions, call Humana Member Services or reference the IPSEN CARES patient support program at 1-866-435-5677.

Support Phone Numbers

Member Services

Primary Number: 800-457-4708 (TTY: 711)
Hours: Monday-Friday, 8 a.m. to 8 p.m. local time
Use for: Prior authorization status, case management, general coverage questions

Provider Support

Provider Services: Use the dedicated number on your provider portal or call the member services line for PA status updates.

Humana Military (if applicable)

Number: 800-444-5445
Hours: Monday-Friday, 8 a.m. to 6 p.m. ET/CT

What to ask when you call:

  • Current status of your prior authorization request
  • Required documentation still needed
  • Expected timeline for decision
  • Appeal options if denied
  • Specialty pharmacy assignment details

Illinois Appeals Process and State Resources

If Humana denies your Somatuline Depot request, Illinois provides strong patient protection through structured appeal rights.

Internal Appeals (First Step)

Timeline: You have 65 days from Humana's denial notice to file an internal appeal
Humana's Response Time: 7 calendar days for Part D appeals, 15 business days for Part C
Expedited Appeals: Available if delay would jeopardize your health (24-72 hour response)

External Review (Illinois-Specific)

If Humana denies your internal appeal, you can request an independent external review under the Illinois Health Carrier External Review Act.

Key Illinois Requirements:

  • Must request within 30 days of final denial (shorter than many states)
  • Independent Review Organization (IRO) assigns a board-certified physician
  • Decision required within 5 business days of receiving all materials
  • No cost to patients - Illinois insurers pay review fees
  • IRO decision is binding on Humana

Illinois State Resources

Illinois Department of Insurance (IDOI)
Consumer Hotline: 877-527-9431
Services: Appeal assistance, external review coordination, consumer rights education

Illinois Attorney General Health Care Bureau
Helpline: 1-877-305-5145
Services: Informal intervention with insurers, complex case assistance

From our advocates: We've seen Illinois patients successfully overturn Humana denials for specialty medications by working closely with the IDOI consumer assistance team. They help ensure all required documentation is complete and can expedite external reviews when medically urgent. The key is acting quickly within Illinois's 30-day external review deadline.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documents
"Off-label use" Provide peer-reviewed evidence and FDA guidance FDA labeling, published studies, clinical guidelines
"No specialist involvement" Obtain referral to endocrinologist or oncologist Specialist consultation notes, treatment plan
"Step therapy not met" Document contraindications or failures with alternatives Prior therapy records, intolerance documentation
"Not medically necessary" Strengthen clinical rationale Comprehensive medical necessity letter, supporting labs/imaging
"Quantity limits exceeded" Justify dosing frequency Clinical evidence for prescribed dosing schedule

Medical Necessity Letter Template Elements

Your prescriber's letter should address:

  • Specific diagnosis with ICD-10 codes
  • Previous treatments attempted and outcomes
  • Clinical rationale for Somatuline Depot specifically
  • Expected treatment goals and monitoring plan
  • References to published treatment guidelines

FAQ

How long does Humana prior authorization take for Somatuline Depot in Illinois?
Standard prior authorization decisions typically take 7-15 business days. Expedited requests (when delay would jeopardize health) are processed within 24-72 hours.

What if Somatuline Depot isn't on my Humana formulary?
You can request a formulary exception by demonstrating medical necessity and submitting supporting clinical documentation. Use Humana's formulary exception process outlined in your plan documents.

Can I request an expedited appeal in Illinois?
Yes, both Humana internal appeals and Illinois external reviews offer expedited processing when delays would seriously jeopardize your health or ability to regain maximum function.

Does step therapy apply if I've tried alternatives outside Illinois?
Yes, document any previous trials of octreotide (Sandostatin LAR) or other somatostatin analogs, regardless of where treatment occurred. Include pharmacy records and physician notes about effectiveness or intolerance.

What's the cost of Somatuline Depot if my appeal fails?
Somatuline Depot ranges from $7,928-$9,348 per syringe. Contact IPSEN CARES at 1-866-435-5677 for patient assistance programs and copay support options.

How do I find my assigned specialty pharmacy?
After prior authorization approval, Humana will assign a specialty pharmacy (often CenterWell Specialty Pharmacy). Contact Humana Member Services at 800-457-4708 for assignment details.

When navigating complex prior authorization requirements, having expert support can make the difference between approval and denial. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to create point-by-point rebuttals that align with payer-specific requirements, pulling the right clinical evidence and regulatory citations to strengthen your case.

For patients facing Somatuline Depot coverage challenges, Counterforce Health's automated system can identify the specific denial basis—whether it's prior authorization criteria, step therapy requirements, or medical necessity questions—and draft appeals that meet Humana's documentation standards while tracking critical deadlines.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan directly for personalized guidance. For assistance with insurance appeals and coverage issues in Illinois, contact the Illinois Department of Insurance at 877-527-9431.

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