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

The Requirements Checklist to Get Signifor LAR (Pasireotide) Covered by Blue Cross Blue Shield in Pennsylvania: Forms, Appeals, and Success Strategies

Answer Box: Getting Signifor LAR Covered by BCBS in Pennsylvania

Signifor LAR (pasireotide) requires prior authorization from all Blue Cross Blue Shield plans in Pennsylvania. The fastest path to approval: (1) Verify your plan's specialty pharmacy network and current PA form, (2) Submit complete documentation including failed first-line treatments and specialist consultation, (3) If denied, file an internal appeal within 180 days, then request Pennsylvania's Independent External Review within 4 months. Pennsylvania's state-run external review program overturns approximately 50% of denials. Start by contacting your BCBS plan's member services to confirm your specific prior authorization requirements.

Table of Contents

Who Should Use This Guide

This checklist is designed for patients with Cushing's disease or acromegaly who need Signifor LAR (pasireotide) covered by Blue Cross Blue Shield plans in Pennsylvania, including:

  • Highmark Blue Shield (western and central PA)
  • Independence Blue Cross (Philadelphia region)
  • Federal Employee Program (BCBS FEP)
  • Medicare Advantage BCBS plans

Expected outcome: Following this systematic approach increases your chances of initial approval and, if needed, successful appeals. Pennsylvania's new external review program has a 50% overturn rate for denials.

Member & Plan Basics

Coverage Requirements at a Glance

Requirement Details Where to Find It
Prior Authorization Always required Highmark Provider Portal or IBX Provider Resources
Formulary Status Specialty tier (covered but restricted) Plan's drug formulary list
Step Therapy Required for acromegaly; varies for Cushing's PA criteria document
Specialty Pharmacy Must use in-network specialty pharmacy Member portal or ID card
Appeals Deadline 180 days for internal; 4 months for external Pennsylvania Insurance Department

Verify Your Coverage First

  1. Check active enrollment - Call the number on your member ID card
  2. Confirm plan type - Commercial, Medicare Advantage, or Federal Employee Program requirements differ
  3. Review deductible status - High-deductible plans may require meeting deductible first
  4. Identify your specific BCBS affiliate - Highmark vs. Independence Blue Cross have different forms and processes

Clinical Criteria Requirements

FDA-Approved Indications

Signifor LAR is approved for:

  • Cushing's disease when surgery is not an option or not curative
  • Acromegaly inadequately controlled by surgery and/or first-generation somatostatin analogs

Step Therapy Documentation

For Cushing's Disease:

  • Documentation of surgical non-candidacy OR
  • Failed/inadequate response to pituitary surgery OR
  • Contraindications to surgery

For Acromegaly:

  • Trial and failure/intolerance of octreotide LAR or lanreotide OR
  • Contraindications to first-generation somatostatin analogs OR
  • Inadequate biochemical control after surgery

Required Lab Values

  • Cushing's disease: Elevated 24-hour urinary free cortisol (UFC) or abnormal dexamethasone suppression test
  • Acromegaly: Elevated IGF-1 levels and/or inadequate GH suppression on oral glucose tolerance test
Tip: Labs should be from within 3-6 months of the PA request for most BCBS plans.

Coding and Billing Information

Essential Codes

Code Type Code Description
HCPCS J-code J2502 Injection, pasireotide long acting, 1 mg
ICD-10 (Cushing's) E24.0 Pituitary-dependent Cushing's disease
ICD-10 (Acromegaly) E22.0 Acromegaly and pituitary gigantism
NDC Examples 0078-0642-81 Signifor LAR 40 mg vial
Note: Always use the exact NDC from the dispensed vial. The temporary code C9454 is no longer valid as of 2025.

Documentation Packet Essentials

Medical Necessity Letter Components

Your prescribing physician should include:

  1. Patient demographics and diagnosis with ICD-10 codes
  2. Clinical presentation - symptoms, disease severity
  3. Prior treatment history - what was tried, outcomes, reasons for discontinuation
  4. Contraindications to alternative therapies
  5. Dosing rationale - why the requested dose/frequency is appropriate
  6. Monitoring plan - how response will be assessed
  7. Literature support - FDA labeling, clinical guidelines, peer-reviewed studies

Required Attachments

  • Recent lab results (UFC, IGF-1, GH levels as appropriate)
  • Clinic notes documenting diagnosis and treatment history
  • Imaging reports (MRI brain/pituitary if available)
  • Previous medication trial documentation
  • Specialist consultation notes (endocrinologist preferred)

Submission Process

Step-by-Step Submission

  1. Obtain current PA form
  2. Complete all required fields
    • Patient information and member ID
    • Prescriber details (NPI, DEA, specialty)
    • Drug information (NDC, strength, quantity, days supply)
    • Clinical justification
  3. Submit via preferred method
    • Electronic: Availity portal for Highmark
    • Fax: Check current fax number on PA form
    • Online: IBX provider portal for Independence Blue Cross
  4. Track submission
    • Record confirmation numbers
    • Note submission date for deadline tracking

Timeline Expectations

  • Standard review: Up to 14 business days
  • Expedited review: 72 hours (if urgent medical need documented)
  • Incomplete submissions: May add 5-10 days for additional information requests

Specialty Pharmacy Requirements

Signifor LAR must be dispensed through your plan's contracted specialty pharmacy network.

Common BCBS Specialty Pharmacy Partners

  • CVS Specialty
  • Accredo (Express Scripts)
  • AllianceRx Walgreens Prime
  • Optum Specialty Pharmacy

Action steps:

  1. Verify your plan's current specialty pharmacy list
  2. Contact the specialty pharmacy to initiate enrollment
  3. Ensure prescription is sent directly to the specialty pharmacy
  4. Coordinate delivery and administration scheduling
Important: Refills typically must go through specialty pharmacy even if initial fill was at retail.

After Submission: What to Expect

Status Monitoring

  • Week 1: Confirmation of receipt
  • Week 2: Determination or request for additional information
  • If approved: Specialty pharmacy will contact you for delivery coordination
  • If denied: You'll receive a written denial letter with specific reasons

What to Record

  • Confirmation numbers and submission dates
  • Case reference numbers
  • Names of representatives you speak with
  • All correspondence received

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"Not medically necessary" Provide detailed clinical rationale, lab values, and specialist support
"Step therapy not met" Document specific trials, doses, durations, and reasons for failure/intolerance
"Non-formulary drug" Request formulary exception with comparative effectiveness data
"Experimental/investigational" Cite FDA approval and established clinical guidelines
"Dosing outside label" Provide literature support or specialist justification for off-label use

Prevention Tips

  1. Use specialist prescribers - Endocrinologists have higher approval rates
  2. Include comprehensive labs - Don't assume payer has access to previous results
  3. Document everything - Specific dates, doses, and outcomes of prior therapies
  4. Submit complete packets - Incomplete submissions cause automatic delays
  5. Follow up promptly - Respond to information requests within stated timeframes

Pennsylvania Appeals Process

If your initial request is denied, Pennsylvania offers one of the strongest patient appeal processes in the country.

Internal Appeals (First Step)

  • Deadline: 180 days from denial letter
  • Process: Submit appeal letter with additional documentation
  • Timeline: 30 days for standard; 72 hours for expedited

Pennsylvania Independent External Review

Pennsylvania launched its state-run external review program in January 2024, with a 50% overturn rate for eligible denials.

Eligibility: Available after completing internal appeals for commercial, marketplace, and direct-purchase plans.

How to file:

  1. Complete internal appeals first
  2. Submit external review request within 4 months of final denial
  3. File online at pa.gov or by mail/fax
  4. Submit supporting documents within 15 business days of assignment

Timeline: 45 days for standard review; 72 hours for expedited urgent cases.

Success Story: In 2024, Pennsylvania's external review program overturned 259 out of 517 eligible appeals, helping patients access previously denied treatments including specialty medications.

At Counterforce Health, we help patients and clinicians turn insurance denials into successful appeals by creating targeted, evidence-backed documentation that addresses payer-specific requirements. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with each payer's own rules, significantly improving approval rates for complex specialty drugs like Signifor LAR.

Quick Reference Checklist

Before You Start:

  • Active BCBS coverage verified
  • Plan type identified (Commercial/Medicare/FEP)
  • Current PA form downloaded
  • Specialty pharmacy network confirmed

Clinical Documentation:

  • Confirmed diagnosis with ICD-10 codes
  • Recent labs (UFC for Cushing's; IGF-1 for acromegaly)
  • Prior treatment trials documented
  • Specialist consultation obtained
  • Medical necessity letter completed

Submission:

  • All form fields completed
  • Supporting documents attached
  • Submitted via correct portal/fax
  • Confirmation number recorded
  • Follow-up scheduled

If Denied:

  • Denial letter reviewed for specific reasons
  • Internal appeal filed within 180 days
  • Additional evidence gathered
  • External review prepared if needed

FAQ

How long does BCBS prior authorization take in Pennsylvania? Standard reviews take up to 14 business days. Expedited reviews (for urgent medical needs) are completed within 72 hours. Incomplete submissions may add 5-10 days.

What if Signifor LAR is non-formulary on my plan? Request a formulary exception by demonstrating medical necessity and providing comparative effectiveness data showing why covered alternatives aren't appropriate.

Can I request an expedited appeal if my condition is worsening? Yes. Both internal appeals and Pennsylvania's external review offer expedited processing (72 hours) when urgent medical circumstances are documented by your physician.

Do I need to use a specific specialty pharmacy? Yes. Signifor LAR must be dispensed through your plan's contracted specialty pharmacy network. Contact member services to confirm approved vendors.

What happens if I pay out-of-pocket during an appeal? If your appeal is successful, BCBS must provide retroactive coverage, including reimbursement for out-of-pocket costs incurred during the appeal process.

How much does Pennsylvania's external review cost? The external review process is free for consumers. Pennsylvania covers all costs associated with the independent review.

Can I get help with my appeal? Yes. Contact the Pennsylvania Insurance Department Consumer Services for free assistance, or organizations like the Pennsylvania Health Law Project provide advocacy support.

What if my doctor isn't an endocrinologist? While any qualified physician can prescribe Signifor LAR, specialist prescribers (endocrinologists) typically have higher approval rates. Consider obtaining a consultation or referral to strengthen your case.

This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and are subject to change. Always verify current requirements with your specific BCBS plan and consult with your healthcare provider for medical decisions.

Need additional help? Contact the Pennsylvania Insurance Department Consumer Services at pa.gov or call the number on your member ID card for plan-specific guidance.

For comprehensive appeal support that addresses your payer's specific requirements, Counterforce Health provides evidence-backed documentation services that have helped thousands of patients successfully appeal insurance denials for specialty medications.

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