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

Myths vs. Facts: Getting Signifor / Signifor LAR (pasireotide) Covered by Cigna in New York

Answer Box: Getting Signifor / Signifor LAR Covered by Cigna in New York

Eligibility: Cigna requires prior authorization for Signifor / Signifor LAR with strict criteria: confirmed Cushing's disease or acromegaly, endocrinologist prescription, documented failure of first-generation somatostatin analogs (for acromegaly), and surgical ineligibility or post-surgical persistence.

Fastest path: Submit comprehensive PA through Cigna's provider portal with recent labs, specialist documentation, and complete treatment history. If denied, New York's external appeal process offers strong patient protections with 50-70% overturn rates for well-documented rare disease cases.

First step today: Contact your endocrinologist to gather all required documentation and confirm they can submit the prior authorization request with complete clinical justification.

Table of Contents

  1. Why Myths Persist About Signifor Coverage
  2. Common Myths vs. Facts
  3. What Actually Influences Approval
  4. Avoid These Critical Mistakes
  5. Quick Action Plan: Three Steps to Take Today
  6. New York Appeals Process
  7. FAQ
  8. Resources

Why Myths Persist About Signifor Coverage

Signifor and Signifor LAR (pasireotide) coverage myths spread because this medication treats rare endocrine conditions that most patients and even some healthcare providers encounter infrequently. The complex prior authorization requirements, combined with Cigna's specialty pharmacy management through Express Scripts and Accredo, create multiple layers where misinformation can take root.

At Counterforce Health, we help patients navigate these exact challenges by turning insurance denials into targeted, evidence-backed appeals. Our platform identifies denial reasons and crafts point-by-point rebuttals using the right clinical evidence and payer-specific requirements.

The stakes are high: Signifor LAR can cost over $20,000 per vial, making coverage denials financially devastating. Understanding the facts—not the myths—is crucial for New York patients seeking this life-changing treatment.

Common Myths vs. Facts

Myth 1: "If my endocrinologist prescribes it, Cigna has to cover it."

Fact: Cigna requires prior authorization for all Signifor formulations, regardless of prescriber specialty. Even endocrinologist prescriptions face strict coverage criteria including documented failure of first-generation somatostatin analogs for acromegaly patients.

Myth 2: "Primary care doctors can prescribe Signifor for insurance coverage."

Fact: Cigna's coverage policy explicitly requires prescription by an endocrinologist or specialist experienced in treating Cushing's disease or acromegaly. Primary care physician prescriptions alone typically result in automatic denials.

Myth 3: "If surgery failed, I automatically qualify for Signifor coverage."

Fact: Surgical failure is just one requirement. You also need recent biochemical evidence of persistent disease (elevated UFC for Cushing's, elevated IGF-1 for acromegaly), age 18+, and for acromegaly patients, documented failure or intolerance to octreotide or lanreotide at maximum tolerated doses.

Myth 4: "Cigna denials can't be overturned in New York."

Fact: New York's external appeal process has 50-70% success rates for well-documented specialty drug cases. The state's Department of Financial Services assigns independent medical experts to review denials, and their decisions are binding on insurers.

Myth 5: "I need to try every possible treatment before Signifor."

Fact: For acromegaly, you must try first-generation somatostatin analogs (octreotide/lanreotide), but not every available treatment. For Cushing's disease, if surgery isn't appropriate or wasn't curative, Signifor can be considered without exhausting all alternatives.

Myth 6: "Express Scripts and Accredo have different approval criteria than Cigna."

Fact: Express Scripts and Accredo follow Cigna's coverage policies for specialty medications. The criteria remain consistent across Cigna's pharmacy benefit management partners.

Myth 7: "Appeals take too long to be worth filing."

Fact: Cigna's internal appeals must be processed within 30 days for standard cases, 72 hours for expedited cases. New York's external appeals are decided within 30 days for standard cases, 72 hours for urgent drug appeals.

Myth 8: "Off-label use is never covered."

Fact: While challenging, off-label coverage is possible with compelling clinical evidence and medical necessity documentation. However, on-label uses (Cushing's disease and acromegaly) have much higher approval rates.

What Actually Influences Approval

Documentation Requirements

Clinical Evidence Needed:

  • Recent laboratory confirmation (within 30 days)
  • Cushing's disease: Elevated 24-hour urinary free cortisol on two occasions
  • Acromegaly: Elevated IGF-1 above age/gender norms, GH >5 ng/mL
  • Complete treatment history with dates, doses, and failure reasons
  • Surgical notes or surgeon's letter explaining ineligibility/inadequate response

Prescriber Credentials:

  • Board-certified endocrinologist preferred
  • Specialist experience with pituitary disorders documented
  • Clear medical necessity letter with clinical rationale

Routing and Submission

Proper Channels:

  • Cigna provider portal for fastest processing
  • CoverMyMeds integration for electronic submissions
  • Complete forms with all required fields and attachments

Timing Considerations:

Avoid These Critical Mistakes

1. Incomplete Treatment History Documentation

The Problem: Missing or vague documentation of prior somatostatin analog trials for acromegaly patients leads to automatic denials.

The Fix: Provide specific dates, doses, duration, and detailed reasons for discontinuation (ineffective response, adverse effects, contraindications).

2. Outdated Laboratory Results

The Problem: Labs older than 30 days may not meet Cigna's current evidence requirements.

The Fix: Obtain fresh hormone levels and include the collection dates prominently in your submission.

3. Non-Specialist Prescribers

The Problem: Primary care or non-endocrinology specialist prescriptions face higher denial rates.

The Fix: Ensure an endocrinologist is the prescriber of record or provides documented consultation supporting the prescription.

4. Insufficient Surgical History Documentation

The Problem: Vague statements about surgical "failure" without specific details.

The Fix: Include operative reports, pathology results, and post-surgical hormone levels demonstrating persistent disease.

5. Missing Age Verification

The Problem: Cigna requires patients be 18 years or older for coverage.

The Fix: Include date of birth and confirm adult status in all submissions.

Quick Action Plan: Three Steps to Take Today

Step 1: Gather Essential Documentation (Today)

Contact your endocrinologist's office and request:

  • Recent hormone lab results (UFC, IGF-1, GH as appropriate)
  • Complete medication history with specific trial details
  • Surgical reports or rationale for surgical ineligibility
  • Current treatment notes and clinical assessments

Step 2: Verify Prescriber Requirements (Within 24 Hours)

Confirm your prescriber is a board-certified endocrinologist or can provide documented specialist consultation. If not, request referral to an appropriate specialist before proceeding with prior authorization.

Step 3: Submit Comprehensive Prior Authorization (Within 48 Hours)

Have your endocrinologist submit the PA through Cigna's provider portal with all required documentation attached. Request expedited review if clinically appropriate.

From our advocates: We've seen cases where patients received approval after initial denials simply by resubmitting with complete treatment history documentation. One composite case involved an acromegaly patient whose first submission lacked specific octreotide trial details—the second submission with pharmacy records and endocrinologist attestation was approved within 48 hours.

New York Appeals Process

If your initial prior authorization is denied, New York offers robust appeal protections:

Internal Appeal with Cigna

  • Timeline: File within 180 days of denial
  • Processing: 30 days for standard, 72 hours for expedited
  • Requirements: Written request with additional clinical evidence

External Appeal Through New York DFS

To file external appeal:

  1. Complete DFS external appeal form
  2. Include all medical records and denial letters
  3. Submit within 4-month deadline
  4. DFS assigns independent medical expert for review

For assistance, contact Community Health Advocates at 888-614-5400.

FAQ

How long does Cigna prior authorization take in New York? Standard reviews are completed within 72 hours, expedited reviews within 24 hours when medically justified.

What if Signifor LAR is non-formulary on my plan? You can request a formulary exception through Cigna's standard prior authorization process. Non-formulary status doesn't prevent coverage if medical necessity is established.

Can I request expedited appeal if denied? Yes, if your provider certifies that waiting could seriously jeopardize your health. Expedited appeals are decided within 72 hours.

Does step therapy apply if I failed treatments outside New York? Yes, documented treatment failures from any location count toward step therapy requirements, provided you have complete medical records.

What counts as "failure" of first-generation somatostatin analogs? Inadequate biochemical response (persistent elevated IGF-1/GH), intolerable side effects, or contraindications at maximum tolerated doses for adequate duration (typically 3-6 months).

Can Counterforce Health help with my Cigna denial? Yes, our platform specializes in turning insurance denials into targeted appeals by identifying specific denial reasons and crafting evidence-backed rebuttals using payer-specific requirements.

Resources

Official Cigna Resources:

New York State Resources:

Clinical Resources:

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies may vary by plan and change over time. Always consult with your healthcare provider and insurance plan for the most current requirements and to determine the best treatment approach for your specific situation.

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