By Counterforce Health Team in Isturisa (osilodrostat) —

Getting Isturisa (Osilodrostat) Covered by Humana in Texas: Complete Guide with Forms and Appeals

Quick Answer: Getting Isturisa (Osilodrostat) Covered by Humana in Texas

Isturisa (osilodrostat) requires prior authorization from Humana, typically for adult Cushing's disease when pituitary surgery isn't an option or hasn't been curative. Your endocrinologist submits the request through Humana's provider portal with documentation including biochemical proof (24-hour urinary free cortisol, late-night salivary cortisol, or dexamethasone suppression test results), surgical history or contraindications, and medical necessity justification. Standard decisions take 7 days; expedited appeals are available for urgent cases. If denied, you have 65 days to appeal, with external review through Texas's Independent Review Organization available as a final step.

First step today: Contact your endocrinologist's office to confirm they have your complete diagnostic workup and surgical history documented for the prior authorization request.

Table of Contents

  1. Coverage Basics: Is Isturisa Covered?
  2. The Prior Authorization Process
  3. Timeline and Urgency Options
  4. Medical Necessity Criteria
  5. Understanding Costs and Coverage
  6. When Denials Happen: Appeals Process
  7. Renewal Requirements
  8. Specialty Pharmacy Requirements
  9. Troubleshooting Common Issues
  10. Frequently Asked Questions

Coverage Basics: Is Isturisa Covered?

Isturisa (osilodrostat) is a specialty medication that requires prior authorization from Humana before coverage begins. As an oral 11β-hydroxylase inhibitor for Cushing's disease, it falls into Humana's high-cost specialty drug category requiring careful review.

Coverage depends on your specific Humana plan type:

  • Medicare Advantage plans: Prior authorization required
  • Medicare Part D plans: Prior authorization required
  • Commercial plans: Prior authorization required (verify with the source linked below)
Note: Humana is eliminating approximately one-third of prior authorizations starting January 2026, but specialty medications like Isturisa are unlikely to be included in these reductions.

To check your specific plan's formulary status, use Humana's drug list search tool and enter your plan details along with "Isturisa" or "osilodrostat."

The Prior Authorization Process

Who Submits the Request?

Your endocrinologist or their office staff submits the prior authorization request. Patients cannot submit these requests directly.

How to Submit

Humana accepts prior authorization requests through multiple channels:

  • Online: Humana provider portal (recommended for fastest processing)
  • Fax: Submit via provider fax (confirm current number with your plan)
  • Phone: For expedited requests only

Required Documentation

Your endocrinologist must include:

  1. Diagnosis confirmation: ICD-10 code E24.0 for Cushing's disease
  2. Biochemical evidence: Results from first-line screening tests including:
    • 24-hour urinary free cortisol (UFC)
    • Late-night salivary cortisol (LNSC)
    • Overnight 1-mg dexamethasone suppression test (DST)
  3. Surgical history: Documentation of why surgery wasn't curative or is contraindicated
  4. Medical necessity letter: Detailed clinical justification

Timeline and Urgency Options

Standard Processing

  • Decision timeline: 7 calendar days from receipt of complete request
  • Member notification: Written determination letter mailed to you
  • Provider notification: Direct communication to prescribing physician

Expedited Reviews

Available when waiting could seriously harm your health. To request expedited review:

  • Call: 800-867-6601
  • Timeline: Decision within 72 hours
  • Requirements: Provider must attest that standard timeline could jeopardize your health
Tip: Starting January 2026, Humana commits to providing decisions within one business day for at least 95% of complete electronic requests.

Medical Necessity Criteria

Diagnostic Requirements

Humana typically requires evidence of confirmed Cushing's disease through multiple screening tests:

Test Type Sensitivity Specificity Clinical Notes
Late-night salivary cortisol >90% Highest among screening tests Multiple collections may be easier for patients
24-hour urinary free cortisol >90% Lower specificity Measures total cortisol excretion
Dexamethasone suppression test Up to 100% Good for first-line screening Optimal sensitivity at 50 nmol/L cutoff

Surgical History Documentation

Your medical necessity letter must clearly document:

  • Previous surgical attempts: Specific dates and approaches
  • Surgical outcomes: Why surgery wasn't curative
  • Contraindications: Medical reasons surgery isn't appropriate
  • Recurrence evidence: Biochemical proof of persistent disease

Prescriber Requirements

Most payers prefer prescriptions from:

  • Board-certified endocrinologists
  • Physicians with documented Cushing's disease expertise
  • Academic medical centers with pituitary programs

Understanding Costs and Coverage

Formulary Placement

Isturisa is typically placed in higher specialty tiers due to its cost and specialized use. Check your specific plan's tier placement through Humana's formulary search.

Cost-Saving Options

  • Manufacturer support: Contact Recordati Rare Diseases for patient assistance programs (verify current offerings)
  • Copay cards: May be available for commercial plans
  • Foundation grants: Research rare disease foundations for additional support

When Denials Happen: Appeals Process

Internal Appeals

You have 65 days from the denial date to file an internal appeal.

How to Appeal:

  1. Online: Through your Humana member portal
  2. Mail/Fax: Using the Appeal, Complaint and Grievance form
  3. Phone: 800-867-6601 for expedited appeals

Timeline: Humana must decide within 7 calendar days for standard appeals, 72 hours for expedited.

External Review in Texas

If Humana denies your internal appeal, Texas law provides independent external review through an Independent Review Organization (IRO).

Key Texas Rights:

  • Available when denial is based on medical necessity
  • You have 4 months from final denial to request external review
  • Free to you - insurer pays for the review
  • Binding decision - if IRO approves, Humana must cover the medication

Timeline for External Review:

  • Standard cases: 20 days
  • Urgent cases: 5 days
  • Expedited concurrent review: Available if delay would jeopardize health

How to Request:

From our advocates: We've seen cases where comprehensive surgical history documentation made the difference in external review. One patient's appeal was initially denied but succeeded at external review when the endocrinologist provided detailed operative reports showing why repeat surgery wasn't feasible due to scar tissue and anatomical changes.

Renewal Requirements

Prior authorizations for specialty medications like Isturisa typically require annual renewal. Your endocrinologist should:

  • Submit renewal 30-60 days before current authorization expires
  • Include updated labs showing ongoing medical necessity
  • Document treatment response and any dose adjustments
  • Confirm continued contraindications to surgery if applicable

Specialty Pharmacy Requirements

Humana may require Isturisa to be dispensed through their preferred specialty pharmacy network. This ensures:

  • Proper storage and handling
  • Clinical monitoring and support
  • Insurance coordination
  • Patient education on administration

Contact Humana at 800-867-6601 to confirm specialty pharmacy requirements for your specific plan.

Troubleshooting Common Issues

Common Problems and Solutions

Issue Solution Contact
Portal access problems Clear browser cache, try different browser Humana tech support
Missing prior therapy documentation Request records from previous providers Your clinic's medical records department
Incomplete lab results Ensure all three screening tests documented Your endocrinologist's office
Prescriber not recognized Verify endocrinology board certification State medical board verification

When to Escalate

Contact the Texas Department of Insurance if:

  • Humana doesn't respond within required timelines
  • You need help understanding your appeal rights
  • You suspect improper denial practices

Texas DOI Consumer Helpline: 1-800-252-3439

Frequently Asked Questions

Q: How long does Humana prior authorization take for Isturisa in Texas? A: Standard decisions are made within 7 calendar days. Expedited reviews for urgent cases are completed within 72 hours.

Q: What if Isturisa isn't on Humana's formulary? A: You can request a formulary exception through the same prior authorization process, with additional documentation of why formulary alternatives aren't appropriate.

Q: Can I request an expedited appeal if my health is deteriorating? A: Yes, call 800-867-6601 to request expedited review when standard timelines could jeopardize your health.

Q: Do I need to try other medications first (step therapy)? A: This depends on your specific plan's requirements. Your endocrinologist can request a step therapy exception if other treatments are inappropriate for your case.

Q: What happens if I move from another state to Texas? A: Your prior authorization should transfer, but contact Humana to confirm coverage continuation and any Texas-specific requirements.

Q: How do I know if my appeal was successful? A: Humana will mail you a written determination letter. You can also check status through your member portal or by calling customer service.

Getting the right coverage support matters. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform ingests denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each plan's requirements, pulling the right medical evidence and citations to support approval.

For additional help navigating Texas insurance appeals, contact the Office of Public Insurance Counsel at 1-877-611-6742 or Disability Rights Texas for advocacy support with complex cases.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Insurance policies and requirements may change; verify current information with official sources.

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