Coverage Policies

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Current policies effective through April 30, 2024.

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INDEX:



Effective Date: 06/01/2013	Title: Signifor (Pasireotide) & Signifor LAR
Revision Date: 01/01/2016	Document: BI411:00
CPT Code(s): None
Public Statement
*Effective Date:* a) This policy will apply to all services performed on or after the above revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. 1) Signifor (Pasireotide) and Signifor LAR require prior authorization. 2) Signifor is used to treat Cushing’s disease. 3) Signifor LAR is used to treat acromegaly. 4) Signifor is a specialty drug and must be obtained through a contracted specialty pharmacy.
Medical Statement
Signifor is considered medically necessary for members who meet the following criteria: 1) Diagnosis of Cushing’s Disease (E24.0) AND 2) Pituitary surgery has not been curative or surgery is not an option (provide rationale). Signifor LAR is considered medical necessary for members who meet the following criteria: 1) Diagnosis of acromegaly (E22.0) AND 2) Had an inadequate response to surgery or surgery is not an option (provide rationale).
Limits
1) Signifor has a quantity limit of 2 units per day for all strengths. 2) Signifor LAR is limited to one dose every 28 days.
Reference
1) Signifor prescribing information. Novartis. East Hanover, NJ. December 2012. 2) Signifor LAR prescribing information. Novartis. East Hanover, NJ. December 2014. 3) Clinical Pharmacology. Signifor. Accessed online May 2013. 4) Colao A, Petersenn S, Newell-Price J, et al. A 12-month Phase 3 study of Pasireotide in Cushing’s disease. NEJM. March 2012 366;10:914-924.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

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