By Counterforce Health Team in Signifor / Signifor LAR (pasireotide) —

Lowering Out-of-Pocket Costs for Signifor LAR (Pasireotide) with UnitedHealthcare in Washington: Complete Guide to Copay Assistance, Tier Exceptions, and Appeals

Quick Answer: Lowering Your Signifor LAR Costs

Signifor LAR (pasireotide) is a high-cost specialty medication typically placed on Tier 4-5 with UnitedHealthcare, meaning significant out-of-pocket costs. However, multiple cost-reduction strategies exist:

  1. Apply for the Recordati copay card (commercial insurance only) - reduces copays to $20 for eligible patients
  2. Request a formulary tier exception if clinical documentation supports medical necessity
  3. Use OptumRx specialty pharmacy exclusively - retail pharmacies cannot dispense Signifor LAR

First step today: Call Recordati's R.A.R.E. Patient Support Program at 1-888-855-RARE (7273) to verify copay assistance eligibility and initiate benefits investigation.

Table of Contents

What Drives Signifor LAR Costs

Understanding your UnitedHealthcare plan's benefit design helps predict and manage Signifor LAR costs.

Formulary Tier Placement

Signifor LAR sits on specialty tiers (Tier 4-5) in most UnitedHealthcare formularies, which means:

  • Higher patient cost-sharing: Often 20-50% coinsurance instead of fixed copays
  • Specialty pharmacy requirement: Must use OptumRx specialty pharmacy
  • Prior authorization mandatory: Clinical documentation required before coverage

Cost Components

Your out-of-pocket costs include:

  • Deductible: Applied before coverage begins (varies by plan)
  • Coinsurance/Copay: Your share after deductible is met
  • Out-of-pocket maximum: Annual limit on your costs
Note: One Signifor LAR vial often costs over $20,000, making even a 20% coinsurance substantial before reaching your out-of-pocket maximum.

Benefit Investigation: What to Ask

Before starting treatment, gather specific cost information from UnitedHealthcare.

Key Questions for Member Services

Call the number on your insurance card and ask:

  1. "Is Signifor LAR (pasireotide) covered on my formulary?"
  2. "What tier is it placed on, and what's my cost-sharing?"
  3. "Has my deductible been met this year?"
  4. "What's my remaining out-of-pocket maximum?"
  5. "Is prior authorization required?"

Information to Record

  • Plan name and member ID
  • Formulary tier and cost-sharing percentage
  • Deductible amount (total and remaining)
  • Out-of-pocket maximum (total and remaining)
  • Prior authorization requirements
  • Specialty pharmacy requirements

Copay Assistance and Patient Support

Recordati R.A.R.E. Copay Program

Commercial insurance patients may qualify for significant copay reduction through Recordati's patient assistance program.

Eligibility Requirements:

  • Commercial insurance coverage (employer-provided, individual marketplace plans)
  • NOT eligible: Medicare, Medicaid, TRICARE, or other government insurance
  • Insurance must cover Signifor LAR (prior authorization may be required first)

Benefits:

  • Copay reduction to $20 per fill for eligible patients
  • Benefits investigation and prior authorization support
  • Appeals assistance if coverage is initially denied

How to Apply:

  1. Call 1-888-855-RARE (7273) (Monday-Friday, 8 AM-8 PM ET)
  2. Complete enrollment with R.A.R.E. team
  3. Provide insurance information for benefits verification
  4. Receive copay card once eligibility is confirmed

Alternative Financial Assistance

If ineligible for copay assistance:

  • Patient Assistance Program: Need-based free drug program for uninsured/underinsured
  • Charitable foundations: Organizations like HealthWell Foundation, Patient Access Network Foundation
  • State programs: Washington Apple Health (Medicaid) if eligible
Tip: The R.A.R.E. team can help identify alternative assistance programs if you don't qualify for the copay card.

Formulary Tier Exceptions

If Signifor LAR is non-formulary or on a high tier, you can request an exception to lower your costs.

When to Request Tier Exceptions

  • Non-formulary status: Drug not covered at all
  • High-tier placement: Tier 4-5 with unaffordable cost-sharing
  • Step therapy requirements: Must try cheaper alternatives first
  • Quantity limitations: Restrictions on monthly supply

Required Documentation

Clinical Justification Must Include:

  • Confirmed diagnosis (Cushing's disease or acromegaly) with ICD-10 codes
  • Documentation that surgery is not an option or has failed
  • For acromegaly: Evidence of inadequate response to first-line agents (octreotide, lanreotide)
  • Baseline laboratory results within 6 months
  • Letter of medical necessity from prescribing endocrinologist

Submission Process

  1. Complete UnitedHealthcare formulary exception form
  2. Gather supporting documentation from your endocrinologist
  3. Submit via OptumRx portal or fax (verify current contact information)
  4. Follow up within 72 hours to confirm receipt
  5. Prepare for potential peer-to-peer review if initially denied

Specialty Pharmacy Requirements

Signifor LAR must be dispensed through OptumRx specialty pharmacy - retail pharmacies cannot fill this prescription under UnitedHealthcare coverage.

OptumRx Specialty Pharmacy Process

Key Requirements:

  • Prior authorization must be approved before dispensing
  • Prescription must come from board-certified endocrinologist (typically required)
  • Patient must complete specialty pharmacy enrollment
  • Home delivery or clinical site coordination available

Cost Differences:

  • Specialty pharmacy: Subject to specialty tier cost-sharing (often percentage-based)
  • Retail pharmacy: Claims will be rejected - no coverage available

Coordination Tips

Working with OptumRx:

  1. Verify prior authorization status before requesting fill
  2. Confirm delivery logistics (home vs. clinic)
  3. Understand refill scheduling (typically 28-day supply)
  4. Maintain communication with your care team about delivery timing

Cost-Based Appeals Process

If your costs remain unaffordable after exploring assistance options, you can appeal on financial hardship grounds.

Washington State Appeal Rights

Internal Appeals (UnitedHealthcare):

  • First level: Standard review (typically 30 days)
  • Second level: Additional internal review if available
  • Expedited: 72 hours for urgent situations

External Review (Washington State):

  • Independent Review Organization (IRO): After exhausting internal appeals
  • Timeline: 180 days from final internal denial to request external review
  • Contact: Washington Office of the Insurance Commissioner at 1-800-562-6900

Documentation for Cost Appeals

Financial Hardship Evidence:

  • Income documentation (pay stubs, tax returns)
  • Medical expenses (other treatments, medications)
  • Hardship letter explaining financial impact
  • Alternative treatment cost comparisons

Annual Renewal Planning

Plan changes can significantly impact your Signifor LAR costs each year.

What Can Change

  • Formulary placement: Tier changes or removal from formulary
  • Cost-sharing structure: Deductible, coinsurance, or copay amounts
  • Prior authorization requirements: New criteria or documentation needs
  • Specialty pharmacy networks: Changes in required pharmacies

Renewal Checklist

  1. Review new formulary (available October-November for following year)
  2. Compare cost-sharing changes in Summary of Benefits
  3. Verify specialty pharmacy requirements
  4. Renew copay assistance programs (typically annual)
  5. Update prior authorizations if required

Counterforce Health helps patients navigate complex insurance requirements by turning denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and creates point-by-point rebuttals aligned with each plan's specific policies.

Conversation Scripts

Calling UnitedHealthcare Member Services

Opening: "Hi, I need to verify coverage details for Signifor LAR, generic name pasireotide, for my [Cushing's disease/acromegaly]. My member ID is [number]."

Key questions to ask:

  • "What's the formulary tier and my cost-sharing percentage?"
  • "Is prior authorization required, and what's the current status?"
  • "What's my remaining deductible and out-of-pocket maximum?"
  • "Which specialty pharmacy must I use?"

Requesting Peer-to-Peer Review

For clinic staff: "I'm requesting a peer-to-peer review for [patient name], member ID [number], for Signifor LAR prior authorization denial. The prescribing physician is Dr. [name], board-certified endocrinologist. When can we schedule the call?"

Pharmacy Coordination Call

To OptumRx: "I'm coordinating Signifor LAR delivery for [patient name]. The prior authorization was approved [date]. Can you confirm the delivery schedule and any patient responsibilities?"

FAQ

How long does UnitedHealthcare prior authorization take for Signifor LAR?

Standard prior authorization typically takes 15 business days, though urgent cases may be expedited to 72 hours. Submit requests at least 14 days before intended start date.

What if Signifor LAR is non-formulary on my plan?

You can request a formulary exception with clinical documentation. If denied, appeal through UnitedHealthcare's internal process, then Washington's external review system.

Can I use the Recordati copay card with Medicare Advantage?

No, federal regulations prohibit copay assistance for government insurance programs, including Medicare Advantage. However, you may qualify for need-based patient assistance programs.

Does step therapy apply if I've tried alternatives outside Washington?

Yes, documentation of prior treatment failures from any location should satisfy step therapy requirements, provided medical records are available.

What happens if I can't afford my specialty tier cost-sharing?

Explore the Recordati patient assistance program, request a formulary tier exception, or contact charitable foundations for additional financial support.

Can I appeal based solely on cost concerns?

While medical necessity is the primary appeal basis, financial hardship can be included as supporting documentation, especially in Washington's external review process.

How do I track my appeal status in Washington?

UnitedHealthcare provides appeal status through their member portal. For external reviews, contact the Washington Office of the Insurance Commissioner at 1-800-562-6900.

What if my employer plan is self-funded?

Self-funded ERISA plans may have different appeal processes. Contact your HR department and consider filing with the U.S. Department of Labor if needed.

From our advocates: We've seen patients successfully reduce their Signifor LAR costs from over $4,000 per month to $20 through the manufacturer copay program combined with thorough prior authorization documentation. The key is starting the benefits investigation early and having your endocrinologist provide comprehensive clinical justification upfront.

Sources & Further Reading

Platforms like Counterforce Health specialize in transforming insurance denials into successful appeals by analyzing payer policies and creating evidence-backed responses tailored to each plan's specific requirements.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.