By Counterforce Health Team in Somatuline Depot (lanreotide) —

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

Quick Answer: Getting Somatuline Depot Covered by Humana in Texas

Eligibility: Humana Medicare Advantage requires prior authorization for Somatuline Depot (lanreotide) for acromegaly, GEP-NETs, and carcinoid syndrome. Fastest path: Have your endocrinologist or oncologist submit PA with documented octreotide trial failure/intolerance, complete diagnostic workup (IGF-1, chromogranin A, or 5-HIAA), and medical necessity letter citing FDA labeling. First step today: Contact your specialist to gather prior treatment records and schedule PA submission through Humana's provider portal. Appeals must be filed within 65 days if denied.

Table of Contents

Humana's Coverage Policy Overview

Humana classifies Somatuline Depot as a high-cost specialty medication requiring prior authorization across all Medicare Advantage plans in Texas. The drug is covered for three FDA-approved indications:

  • Acromegaly (growth hormone excess)
  • Gastroenteropancreatic neuroendocrine tumors (GEP-NETs)
  • Carcinoid syndrome (NET-related symptoms)

Coverage applies to both Medicare Part B (when administered in clinical settings) and Part D (specialty pharmacy dispensing), though requirements may vary slightly between benefit types.

Note: Private fee-for-service Medicare Advantage plans may have different PA requirements—verify your specific plan type through Humana member services.

Medical Necessity Requirements

Humana's medical necessity criteria for Somatuline Depot include:

Core Documentation Needed

  • Confirmed diagnosis with appropriate ICD-10 codes
  • Specialist involvement: Endocrinologist (acromegaly) or oncologist (NETs/carcinoid)
  • FDA-approved indication: On-label use strongly preferred
  • Clinical rationale for choosing lanreotide over alternatives
  • Treatment goals and monitoring plan

Coverage Criteria by Condition

Condition Key Requirements Supporting Evidence
Acromegaly Failed/unsuitable for surgery/radiation; elevated IGF-1 IGF-1 levels, pituitary imaging, endocrine evaluation
GEP-NETs Unresectable, locally advanced, or metastatic disease Histology, imaging, chromogranin A levels
Carcinoid Syndrome Biochemically confirmed; symptomatic disease 5-HIAA (urine), chromogranin A, symptom documentation

Step Therapy and Required Trials

Octreotide trial requirement: Humana typically requires documented trial and failure (or medical contraindication) of octreotide (Sandostatin LAR) before approving Somatuline Depot, unless the request falls under Medicare Part B medical benefit coverage.

Acceptable Documentation of Prior Therapy

  • Treatment duration: Minimum 3-month trial at therapeutic doses
  • Outcome documentation: Lack of efficacy, intolerance, or adverse events
  • Medical contraindications: Documented reasons octreotide cannot be used
  • Specialist attestation: Letter confirming inadequate response or intolerance

Exceptions to Step Therapy

  • Medicare Part B administration (clinic-based infusion)
  • Documented allergic reaction to octreotide
  • Contraindication based on patient-specific factors
  • Prior authorization for continuation of established therapy
Clinician Tip: Document specific octreotide doses tried, duration of treatment, objective measures of response (lab values, symptom scores), and reasons for discontinuation to strengthen your PA request.

Quantity Limits and Dosing Rules

Humana enforces strict quantity limits aligned with FDA labeling:

Standard Coverage Limits

  • Maximum frequency: One syringe every 28 days
  • Dose range: 60mg, 90mg, or 120mg strengths
  • Standard maximum: 120mg every 4 weeks

Exceptions for Higher Frequency

  • Every 14 days: Requires documented progression on standard dosing
  • Medical justification: Must demonstrate clinical need for increased frequency
  • Specialist support: Oncologist documentation for progressive NETs

Required Diagnostic Evidence

Acromegaly Diagnostic Requirements

  • IGF-1 levels: Elevated above age- and sex-adjusted reference ranges
  • Growth hormone suppression test: Inadequate suppression after oral glucose tolerance
  • Pituitary imaging: MRI confirmation of adenoma (when applicable)
  • Clinical symptoms: Documented acromegaly features

GEP-NET and Carcinoid Syndrome Requirements

  • Chromogranin A: Elevated levels (useful for monitoring, not diagnosis alone)
  • 5-HIAA (24-hour urine): Essential for carcinoid syndrome diagnosis
  • Histological confirmation: Tissue diagnosis when available
  • Imaging studies: CT/MRI/octreotide scan showing tumor burden
Important: For accurate 5-HIAA testing, patients must avoid specific foods (bananas, avocados, tomatoes) and medications for 24 hours before and during collection.

Specialty Pharmacy Requirements

Somatuline Depot must be dispensed through Humana-contracted specialty pharmacies for Part D coverage:

  • Network requirement: Must use approved specialty pharmacy
  • Coordination: Pharmacy handles PA submission and clinical coordination
  • Delivery: Scheduled delivery aligned with 28-day dosing
  • Storage: Requires refrigeration and proper handling

For Medicare Part B coverage (clinic administration), the drug may be purchased through specialty distributors and billed as a medical benefit.

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic)
    • Insurance card and policy details
    • Complete medical records showing diagnosis
    • Prior octreotide treatment history and outcomes
    • Recent lab results (IGF-1, chromogranin A, or 5-HIAA)
  2. Specialist Consultation (Within 1 week)
    • Schedule with endocrinologist (acromegaly) or oncologist (NETs)
    • Confirm FDA-approved indication
    • Document medical necessity rationale
  3. Prior Authorization Submission (Physician)
    • Submit through Humana provider portal
    • Include comprehensive medical necessity letter
    • Attach all supporting documentation
    • Timeline: Standard decisions within 72 hours
  4. Track Status (Patient/Clinic)
    • Monitor through provider portal or member services
    • Follow up if no response within 3 business days
    • Request expedited review if clinically urgent
  5. Specialty Pharmacy Setup (Upon approval)
    • Contact Humana-approved specialty pharmacy
    • Coordinate delivery and administration schedule
    • Confirm coverage details and copay

Appeals Process in Texas

If your initial PA request is denied, Texas residents have strong appeal rights:

Internal Appeal (First Level)

  • Deadline: 65 days from denial notice
  • Decision timeline: 30 days for pre-service requests
  • Submission: Via Humana member portal or written request
  • Required documents: Original denial letter, additional clinical evidence

External Review Options

For Medicare Advantage plans, continue through the federal Medicare appeals process after Humana's internal review. For other plan types, Texas offers Independent Review Organization (IRO) appeals:

  • IRO deadline: 4 months from final internal denial
  • Decision timeline: 20 days (standard), 5 days (urgent)
  • Cost: No charge to patient
  • Binding decision: Insurer must comply with IRO approval

Texas Resources for Appeals Assistance

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742
  • Online appeals guidance: Texas DOI website

Common Denial Reasons and Solutions

Denial Reason Solution Strategy
Insufficient prior octreotide trial Document 3+ month trial with specific doses, dates, and outcomes
Lack of specialist involvement Obtain referral to endocrinologist or oncologist for evaluation
Missing diagnostic confirmation Submit complete lab results (IGF-1, chromogranin A, 5-HIAA as appropriate)
Off-label use concern Provide FDA labeling excerpt and peer-reviewed evidence supporting indication
Quantity limit exceeded Submit clinical justification for higher frequency with specialist support

Costs and Patient Assistance

Insurance Coverage

  • Medicare Part D copay: Varies by plan tier (typically $100-500+ per month)
  • Part B coinsurance: 20% after deductible for clinic administration

Patient Assistance Programs

  • Ipsen Cares: Manufacturer copay assistance and patient support program
  • Foundation support: NORD, PAN Foundation, and other rare disease organizations
  • State programs: Limited options in Texas due to Medicaid non-expansion
From Our Advocates: We've seen patients successfully appeal Humana denials by working closely with their specialist to document a clear progression of symptoms despite adequate octreotide therapy. The key was submitting objective measures—lab values and imaging—rather than just symptom reports. Most successful appeals included both the original treatment records and a detailed letter explaining why lanreotide was specifically needed over alternatives.

FAQ

How long does Humana prior authorization take for Somatuline Depot in Texas? Standard PA decisions are typically made within 72 hours of complete submission. Expedited reviews (for urgent cases) are decided within 24 hours.

What if Somatuline Depot is not on Humana's formulary? Submit a formulary exception request with your PA. This requires additional documentation showing medical necessity and why formulary alternatives are inappropriate.

Can I request an expedited appeal if denied? Yes, if a delay in treatment would jeopardize your health. Both internal appeals and external reviews offer expedited timelines in Texas.

Does the octreotide trial requirement apply if I was treated outside Texas? No, prior treatment history from any location counts toward step therapy requirements. Ensure you have complete documentation from out-of-state providers.

What happens if I'm on Somatuline Depot and switch to Humana? Humana may honor continuation of established therapy, but you'll likely need to complete a PA process. Start this immediately upon enrollment to avoid treatment gaps.

Are there quantity limit exceptions for progressive disease? Yes, patients with documented disease progression on standard 28-day dosing may qualify for every-14-day administration with proper specialist documentation.

At Counterforce Health, we help patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by identifying the specific denial basis and crafting targeted, evidence-backed responses. Our platform ingests denial letters, plan policies, and clinical notes to draft point-by-point rebuttals that align with each payer's own rules, pulling the right citations and clinical facts to support medical necessity arguments.

Sources and Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Coverage policies and appeal procedures may change. Always verify current requirements with your insurance plan and consult healthcare providers for medical decisions. For personalized assistance with Humana appeals in Texas, consider working with Counterforce Health to develop targeted, evidence-based appeal strategies.

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