By Counterforce Health Team in Somatuline Depot (lanreotide) —

How to Get Somatuline Depot (Lanreotide) Covered by Humana in New York: Prior Authorization, Appeals, and Cost Assistance Guide

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

Fastest path to approval: Submit Humana's prior authorization form with diagnosis (acromegaly, GEP-NET, or carcinoid syndrome), prior therapy documentation, and clinical justification. Humana typically covers Somatuline Depot on specialty tier with PA required. If denied, you have 65 days to appeal and can request external review through New York's Department of Financial Services within 4 months.

First step today: Call Humana member services to verify formulary status and PA requirements for your specific plan, then have your endocrinologist or oncologist submit the PA request with complete clinical documentation.

Table of Contents

  1. Coverage at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Prior Authorization Requirements
  4. Common Denial Reasons & Solutions
  5. Appeals Process in New York
  6. Financial Assistance Options
  7. Specialty Pharmacy Coordination
  8. Scripts for Key Conversations
  9. FAQ

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required Must get approval before coverage Humana provider portal Humana PA policy
Formulary Tier Specialty tier (high coinsurance) 2024 Humana formulary Plan documents
Covered Indications Acromegaly, GEP-NET, carcinoid syndrome FDA label Clinical policy
Quantity Limit One syringe every 28 days Humana drug list Utilization management
Appeals Deadline 65 days from denial CMS appeals guidance Medicare rules

Step-by-Step: Fastest Path to Approval

1. Verify Your Coverage (Patient/Clinic Staff)

  • Action: Call Humana member services (number on your ID card)
  • Ask for: Formulary status, tier placement, PA requirements for Somatuline Depot
  • Timeline: 10-15 minutes
  • Document: Plan name, contract number, PA fax number

2. Gather Clinical Documentation (Prescriber)

  • Required: Diagnosis with ICD-10, prior therapy history, treatment failures/intolerances
  • Timeline: 1-2 days to compile records
  • Key documents: Lab results, imaging, previous medication trials
  • Source: Humana PA criteria

3. Submit Prior Authorization (Prescriber)

  • Method: Fax to 1-888-447-3430 or submit via Humana provider portal
  • Required form: Humana Medicare Part D Coverage Determination form
  • Timeline: Submit within 24-48 hours of gathering documents
  • Expedited option: Available if delay threatens health

4. Await Decision (Patient/Prescriber)

  • Standard timeline: 72 hours for coverage determination
  • Expedited timeline: 24 hours if urgent
  • Track status: Through Humana provider portal or member services

5. If Approved: Coordinate Specialty Pharmacy

  • Typical assignment: CenterWell Specialty Pharmacy
  • Delivery: White-bagged to prescriber's office
  • Storage: Requires refrigeration upon delivery

6. If Denied: File Appeal Within 65 Days

  • Internal appeal: Redetermination with Humana
  • External review: New York Department of Financial Services if internal appeal fails
  • Timeline: 4 months from final denial for external review

Prior Authorization Requirements

Humana's clinical policy for Somatuline Depot requires documentation of:

Covered Indications

  • Acromegaly in adults with inadequate response to surgery/radiation
  • Unresectable GEP-NETs (well or moderately differentiated)
  • Carcinoid syndrome with flushing and/or diarrhea

Required Clinical Information

  • Confirmed diagnosis with appropriate ICD-10 codes
  • Documentation of disease severity and functional impact
  • Prior treatment history, including:
    • Surgical interventions attempted
    • Previous medications tried and outcomes
    • Contraindications to preferred alternatives
  • Planned dosing schedule (60-120 mg every 4 weeks)
Clinician Corner: When completing the PA request, reference specific FDA-approved indications and include objective measures of disease activity (IGF-1 levels for acromegaly, chromogranin A for NETs). Document any previous octreotide trials and their outcomes, as some plans require step therapy.

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
"Not medically necessary" Provide clinical guidelines and objective disease markers NCCN guidelines, lab values, imaging
"Step therapy not completed" Document contraindications or previous failures with preferred agents Detailed medication history, adverse events
"Off-label use" Reference FDA labeling or recognized compendia FDA package insert, NCCN guidelines
"Quantity limit exceeded" Justify dosing frequency based on patient response Clinical notes showing inadequate control with standard dosing

Appeals Process in New York

Internal Appeal (Redetermination)

  • Deadline: 65 days from denial notice
  • Method: Written request to Humana with additional clinical information
  • Timeline: 7 days for standard, 72 hours for expedited
  • Required: Original PA request plus new supporting evidence

External Review (New York DFS)

New York offers one of the strongest external appeal systems in the nation:

  • Eligibility: After receiving final adverse determination from Humana
  • Deadline: 4 months from final denial
  • Cost: $25 maximum (waived for Medicaid or financial hardship)
  • Timeline: 30 days standard, 72 hours expedited, 24 hours for urgent drug denials
  • Binding: Decision is final and enforceable against the insurer

How to file: Submit through the New York DFS Portal or mail forms to the Department of Financial Services.

Note: New York's external reviewers are independent medical experts who can overturn denials based on medical literature. The state publishes a searchable database of past decisions that can help inform your appeal strategy.

Additional New York Resources

  • Community Health Advocates: Free counseling at 888-614-5400
  • New York State Department of Health: Coordinates with DFS for Medicaid appeals

Financial Assistance Options

Manufacturer Support (IPSEN CARES)

Copay Assistance Program:

  • Eligibility: Commercial insurance only (NOT Medicare/Medicaid)
  • Benefit: May pay as little as $0 per prescription
  • Exclusions: Massachusetts, California, Rhode Island residents have restrictions
  • Contact: 866-435-5677

Patient Assistance Program:

  • Eligibility: Uninsured or "functionally uninsured" with financial hardship
  • Benefit: Free Somatuline Depot
  • Medicare patients: May qualify if coverage gaps exist and income criteria met
  • Application: Through prescriber's office

Foundation Grants

HealthWell Foundation:

  • Acromegaly Fund: Up to assistance for eligible patients
  • NET Fund: Separate program for neuroendocrine tumor patients
  • Income limit: Generally up to 500% of Federal Poverty Level
  • Status: Check current availability as funds close when capacity reached

PAN Foundation:

  • Acromegaly (Medicare) Program: Specifically for Medicare beneficiaries
  • Coverage: Part B and Part D copays, coinsurance, deductibles
  • Application: Online or by phone when program is open

Specialty Pharmacy Coordination

Humana typically requires Somatuline Depot to be dispensed through their specialty pharmacy network:

CenterWell Specialty Pharmacy

  • Primary network: Humana-owned specialty pharmacy
  • Process: White-bagging to prescriber's office
  • Coordination: Pharmacy contacts office to schedule delivery
  • Storage: Requires immediate refrigeration

Best Practices for Providers

  1. Verify specialty pharmacy assignment after PA approval
  2. Establish protocols for receiving refrigerated shipments
  3. Schedule patient visits around delivery timing
  4. Maintain cold chain storage until administration

Counterforce Health helps patients and providers streamline this complex process by analyzing denial letters and crafting targeted appeals with the right clinical evidence and procedural requirements for each payer's specific policies.

Scripts for Key Conversations

Calling Humana Member Services

"Hi, I need to verify coverage for Somatuline Depot for [patient name/member ID]. Can you tell me: Is it on the formulary? What tier? Is prior authorization required? What's the PA fax number for my provider? Are there any step therapy requirements?"

Provider Peer-to-Peer Request

"I'm requesting a peer-to-peer review for [patient] who needs Somatuline Depot for [indication]. We've documented [prior therapies tried] and [clinical rationale]. When can we schedule the clinical discussion with your medical director?"

Specialty Pharmacy Coordination

"We have PA approval for Somatuline Depot. Please confirm: delivery address, refrigeration requirements, advance notice needed, and contact person for scheduling patient visits around deliveries."

FAQ

How long does Humana prior authorization take for Somatuline Depot in New York? Standard decisions within 72 hours, expedited within 24 hours if clinically urgent. Specialty drugs often require additional review time.

What if Somatuline Depot is non-formulary on my Humana plan? Request a formulary exception with medical necessity documentation. Your prescriber must demonstrate that all formulary alternatives would be less effective or cause adverse effects.

Can I request an expedited appeal in New York? Yes, if waiting for standard appeal timing would seriously jeopardize your health. New York allows 72-hour expedited external appeals, or 24 hours for urgent drug denials.

Does step therapy apply if I've been stable on Somatuline Depot? Document previous stability and risk of changing therapy. Humana may waive step therapy if switching poses significant clinical risk.

What happens if I can't afford the specialty tier copay? Explore manufacturer assistance programs, foundation grants, and consider requesting a tiering exception if lower-tier alternatives are medically inappropriate.

How do I file an external appeal with New York DFS? After exhausting Humana's internal appeals, submit a request through the New York DFS Portal within 4 months of the final denial. Include all medical records and denial letters.

This guide provides educational information about insurance coverage and appeals processes. It is not medical advice. Consult your healthcare provider for medical decisions and contact New York's Department of Financial Services or Community Health Advocates for personalized insurance assistance.

Sources & Further Reading:

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