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

Lowering Out-of-Pocket for Signifor / Signifor LAR (pasireotide) with UnitedHealthcare in New Jersey: Copay, Tiering & Assistance

Quick Answer: Reducing Your Signifor LAR Costs with UnitedHealthcare in New Jersey

UnitedHealthcare requires prior authorization for Signifor LAR (pasireotide) with potential high specialty tier costs. Key cost-reduction strategies include the manufacturer's $20 copay program for commercial insurance, foundation grants up to $13,600/year, and formulary tier exception requests. Start by enrolling in the R.A.R.E. Patient Support Program at 1-888-855-RARE (7273) while your provider submits PA documentation including elevated cortisol labs and surgical history. If denied, New Jersey's Independent Health Care Appeals Program (IHCAP) provides external review through Maximus Federal Services within 180 days of final denial.

Table of Contents

  1. What Drives Signifor LAR Costs
  2. Benefit Investigation: What to Ask
  3. Assistance Options
  4. Tiering Exceptions
  5. Pharmacy Choice & Coordination
  6. Appeals on Cost Grounds
  7. Renewal Budgeting
  8. Conversation Scripts
  9. FAQ

What Drives Signifor LAR Costs

Understanding your UnitedHealthcare benefit design helps predict and reduce out-of-pocket costs for Signifor LAR, which often exceeds $20,000 per monthly injection.

Benefit Design Basics

Formulary Tier Placement UnitedHealthcare typically places Signifor LAR on Tier 4-5 specialty tiers, requiring:

  • Prior authorization through OptumRx
  • Higher coinsurance (often 25-40%) vs. lower-tier copays
  • Specialty pharmacy dispensing requirements

Cost-Sharing Structure Your specific costs depend on:

  • Deductible status: High-deductible plans require meeting deductible first
  • Coinsurance percentage: Specialty tiers often use coinsurance vs. flat copays
  • Out-of-pocket maximum: Annual cap on your total costs
Tip: Request your Summary of Benefits and Coverage (SBC) to understand exact specialty tier cost-sharing before starting therapy.

Factors Influencing Tiering

UnitedHealthcare's formulary decisions consider:

  • Clinical effectiveness compared to alternatives
  • Cost-effectiveness analysis
  • Manufacturer rebate agreements
  • Step therapy protocols (required for acromegaly, not Cushing's disease)

Benefit Investigation: What to Ask

Contact UnitedHealthcare member services with your insurance card ready to gather essential cost information.

Information to Record

Coverage Details

  • Formulary tier for Signifor LAR (pasireotide)
  • Prior authorization status and requirements
  • Deductible amount and current status
  • Specialty tier coinsurance percentage
  • Out-of-pocket maximum and year-to-date spending

Pharmacy Network

  • Required specialty pharmacy options
  • In-network vs. out-of-network cost differences
  • Mail-order availability and pricing

Key Questions Script

  1. "What tier is Signifor LAR on my formulary?"
  2. "What's my specialty medication coinsurance percentage?"
  3. "Have I met my deductible for this year?"
  4. "Which specialty pharmacies are in-network?"
  5. "Is there a quantity limit per month?"

Assistance Options

Multiple financial assistance programs can dramatically reduce your Signifor LAR costs.

Manufacturer Copay Programs (Commercial Insurance Only)

R.A.R.E. Patient Support Program Recordati Rare Diseases offers comprehensive support including:

  • $20 copay for qualified commercially insured patients
  • Home injection program at no additional cost
  • Insurance verification and prior authorization assistance
  • Clinical nurse educator support

Contact: 1-888-855-RARE (7273), Monday-Friday 8:00 AM–8:00 PM ET

Eligibility Requirements

  • Commercial insurance coverage (not government plans)
  • Valid prescription for Signifor LAR
  • Income and insurance restrictions may apply (verify during enrollment)

Foundation Grants

HealthWell Foundation Covers Signifor LAR copays for eligible patients:

  • Income up to 300-500% of Federal Poverty Level
  • Must have insurance covering part of treatment costs
  • Average grant: $2,200 per 12-month period
  • Apply online

PAN Foundation Disease-specific assistance:

  • Acromegaly fund: Up to $13,600/year
  • Cushing's disease fund: Up to $11,600/year
  • Income eligibility varies by fund
  • Check current availability
Note: Foundation funding opens and closes throughout the year. Apply as soon as you're prescribed Signifor LAR.

Case Management Support

OptumRx Specialty Pharmacy Services UnitedHealthcare's specialty pharmacy provides:

  • Benefits verification and cost estimation
  • Prior authorization submission and tracking
  • Coordination with manufacturer assistance programs
  • Delivery and injection training support

Tiering Exceptions

When Signifor LAR's specialty tier creates unaffordable costs, request a formulary exception to lower-tier cost-sharing.

When to Request Exceptions

Medical Necessity Scenarios

  • Alternative lower-tier medications failed or caused intolerable side effects
  • Clinical contraindications to preferred alternatives
  • Unique dosing requirements not met by formulary options

Financial Hardship

  • Specialty tier costs exceed reasonable percentage of income
  • Fixed income situations with limited medication budgets
  • Temporary financial difficulties

Evidence to Include

Clinical Documentation

  • Detailed medical necessity letter from endocrinologist
  • Lab results showing elevated cortisol (UFC, late-night salivary cortisol)
  • Documentation of prior medication failures or contraindications
  • Treatment history and response to previous therapies

Financial Documentation

  • Income verification (tax returns, pay stubs)
  • Household expense documentation
  • Other medical costs and medications

Submission Process

  1. Request exception form from UnitedHealthcare member services
  2. Provider completes medical necessity section with supporting documentation
  3. Submit via UHC Provider Portal, fax, or mail (verify current submission method)
  4. Follow up within 5-7 business days for status updates

Pharmacy Choice & Coordination

Specialty pharmacy selection affects costs, convenience, and support services.

Specialty vs. Mail-Order Options

OptumRx Specialty Pharmacy

  • In-network rates with UnitedHealthcare
  • Integrated prior authorization and benefits verification
  • Clinical support and injection training
  • Home delivery coordination

Alternative Specialty Pharmacies

  • Verify in-network status before transferring
  • Compare copay assistance program acceptance
  • Evaluate clinical support services offered

Coordination Tips

Manufacturer Program Integration

  • Ensure chosen pharmacy participates in R.A.R.E. program
  • Confirm copay card processing capabilities
  • Verify home injection service availability

Delivery and Storage

  • Schedule delivery for refrigerated medication
  • Plan for travel and vacation coverage
  • Understand emergency replacement procedures

Appeals on Cost Grounds

When coverage is approved but costs remain prohibitive, appeal the cost-sharing determination.

When Appeals Are Relevant

Coverage Scenarios

  • Prior authorization approved but placed on unaffordable tier
  • Quantity limits reducing cost-effectiveness of manufacturer programs
  • Network restrictions forcing out-of-network costs

Documentation Needed

Financial Impact Evidence

  • Comparison of Signifor LAR costs to household income
  • Documentation of financial hardship
  • Alternative medication cost comparisons

Clinical Necessity

  • Endocrinologist letter supporting medical necessity
  • Evidence of treatment urgency (progressive symptoms)
  • Contraindications to lower-cost alternatives

New Jersey Appeals Process

Internal Appeals (UnitedHealthcare)

  • Timeline: 180 days from denial
  • Levels: Up to two internal appeal levels
  • Submission: UHC member portal, mail, or fax

External Review (IHCAP)

  • Timeline: 180 days from final internal denial
  • Administrator: Maximus Federal Services
  • Cost: Free to patients
  • Contact: 1-888-393-1062
Important: New Jersey's Independent Health Care Appeals Program has physician reviewers who can overturn insurer cost-sharing decisions based on medical necessity.

Renewal Budgeting

Plan ahead for annual changes that affect Signifor LAR costs.

What Can Change Annually

Formulary Updates

  • Tier placement modifications
  • Prior authorization requirement changes
  • Quantity limit adjustments
  • Preferred pharmacy network updates

Benefit Design Changes

  • Deductible amounts
  • Coinsurance percentages
  • Out-of-pocket maximums
  • Specialty tier definitions

Renewal Reminders

October-November

  • Review next year's formulary and benefit changes
  • Renew manufacturer copay program enrollment
  • Check foundation grant renewal deadlines

December

  • Submit any necessary formulary exception requests
  • Coordinate with specialty pharmacy for January transition
  • Update insurance information with all assistance programs

Conversation Scripts

Use these templates when speaking with different stakeholders about Signifor LAR costs.

UnitedHealthcare Member Services Script

"Hi, I'm calling about coverage for Signifor LAR, a medication for Cushing's disease. My member ID is [ID number]. I need to understand:

  1. What tier is Signifor LAR on my plan?
  2. What's my specialty medication coinsurance?
  3. Are there any quantity limits?
  4. Which specialty pharmacies are in-network?
  5. How do I request a formulary exception if needed?"

Specialty Pharmacy Script

"I'm starting Signifor LAR and want to understand my out-of-pocket costs. Can you:

  1. Verify my insurance benefits and estimated copay?
  2. Help me enroll in the manufacturer's copay assistance program?
  3. Check if I qualify for any foundation grants?
  4. Explain your home injection training services?"

Provider Office Script

"I need help with prior authorization for Signifor LAR. Please include:

  1. My elevated cortisol lab results
  2. Documentation that surgery wasn't curative
  3. Any prior medication trials and outcomes
  4. A medical necessity letter addressing UnitedHealthcare's criteria
  5. Request for formulary exception if tier placement creates financial hardship"

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex insurance approvals by turning denials into targeted, evidence-backed appeals. The platform automates the creation of comprehensive prior authorization requests and appeals, incorporating payer-specific requirements and clinical evidence to improve approval rates for specialty medications like Signifor LAR.

FAQ

How long does UnitedHealthcare prior authorization take for Signifor LAR? Standard reviews take up to 15 business days, while urgent cases receive decisions within 72 hours. Submit requests 30-45 days before needed therapy to account for potential appeals.

What if Signifor LAR isn't on UnitedHealthcare's formulary? Request a formulary exception with medical necessity documentation. New Jersey patients can appeal negative decisions through the Independent Health Care Appeals Program (IHCAP) for external physician review.

Can I use manufacturer copay assistance with government insurance? No, federal law prohibits manufacturer copay cards for Medicare, Medicaid, and other government programs. Foundation grants remain available for eligible patients.

Does step therapy apply to Signifor LAR for Cushing's disease? No, UnitedHealthcare doesn't require step therapy for Cushing's disease indications. Step therapy applies only for acromegaly treatment.

How do I expedite an appeal for urgent medical situations? Request expedited review when delays would cause serious harm. UnitedHealthcare must respond within 72 hours for urgent cases, and New Jersey's IHCAP offers expedited external review.

What happens if I move out of New Jersey during treatment? Your UnitedHealthcare coverage continues, but appeal rights follow your new state's regulations. Contact your new state insurance department for external review procedures.

Can my doctor request a peer-to-peer review? Yes, endocrinologists can request peer-to-peer discussions with UnitedHealthcare medical directors to discuss clinical necessity and address denial reasons directly.

Sources & Further Reading

This information is for educational purposes only and does not constitute medical or legal advice. Consult your healthcare provider and insurance plan for personalized guidance. For additional help with New Jersey insurance issues, contact the NJ Department of Banking and Insurance Consumer Hotline at 1-800-446-7467.

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