By Counterforce Health Team in Isturisa (osilodrostat) —

How to Get Isturisa (Osilodrostat) Covered by Aetna (CVS Health) in Virginia: Complete Guide with Forms, Appeals, and Timelines

Quick Answer: Getting Isturisa (Osilodrostat) Approved by Aetna (CVS Health) in Virginia

Aetna requires prior authorization for Isturisa (osilodrostat) in adults with confirmed Cushing's disease when surgery has failed or is contraindicated. Submit the specialty PA form via Aetna's provider portal or fax to 1-877-269-9916 with diagnosis confirmation, surgical history, and endocrinologist prescription. If denied, you have 180 days to appeal internally, then 120 days for Virginia's external review process through the State Corporation Commission Bureau of Insurance (1-877-310-6560).

First step today: Verify your Aetna plan covers specialty drugs and gather your surgical records, cortisol lab results, and endocrinologist notes.

Table of Contents

Verify Your Aetna Plan and Find the Right Forms

Before starting your Isturisa prior authorization, confirm your specific Aetna plan type and specialty drug benefits. This determines which forms you'll need and what approval pathway to follow.

Check your plan details:

  • Log into your Aetna member portal using your member ID
  • Review your prescription drug benefits summary for specialty tier coverage
  • Verify your deductible status and copay amounts for specialty medications
  • Confirm CVS Specialty Pharmacy is your designated specialty provider
Note: Isturisa is typically classified as a Tier 4-5 specialty medication and may be non-formulary on some Aetna plans, requiring a medical exception request.

Prior Authorization Forms and Requirements

Core Coverage Criteria

Aetna requires specific documentation to approve Isturisa for Cushing's disease. Here's what your endocrinologist needs to include:

Requirement Documentation Needed Source
Age verification Patient 18+ years old Aetna specialty PA criteria
Diagnosis confirmation ICD-10: E24.0 with lab evidence (24-hour UFC, late-night salivary cortisol, or dexamethasone suppression test) FDA prescribing information
Surgical requirement Documentation of failed pituitary surgery or contraindication Aetna medical policy
Prescriber qualification Endocrinologist prescription or consultation notes CVS Health PA requirements

Essential Forms

Primary Form: Aetna Specialty Medication Prior Authorization Request

Supporting Documents:

  • Letter of Medical Necessity (template available from your endocrinologist)
  • Recent lab results showing elevated cortisol levels
  • Surgical records or contraindication documentation
  • Previous treatment history and failures

Submission Portals and Methods

Fastest Submission Methods

Method Contact Processing Time Best For
Availity Portal availity.com Real-time tracking Providers with portal access
Specialty Fax 1-877-269-9916 24-48 hours Complete documentation packages
Phone (urgent) 1-855-240-0535 Immediate guidance Status checks and expedited requests
Mail 1300 E Campbell Rd, Richardson, TX 75081 5-7 business days Appeals and exceptions
Tip: Always request a confirmation number when submitting by phone or fax. Track your submission status through the Aetna provider portal within 2-3 business days.

Complete Your Forms Checklist

Before submitting, ensure you have:

  • Patient demographics and insurance information
  • Prescriber NPI number and contact details
  • ICD-10 diagnosis codes (E24.0 for Cushing's disease)
  • Height, weight, and allergy information
  • Complete treatment history with dates and outcomes
  • Recent cortisol lab values with reference ranges
  • Surgical records or contraindication documentation

CVS Specialty Pharmacy Enrollment

Once your prior authorization is approved, you'll need to enroll with CVS Specialty Pharmacy for Isturisa dispensing.

Patient Enrollment Steps

  1. Text "START" to 28779 or visit CVSspecialty.com/newpatient immediately after your prescription is written
  2. Create your online account for prescription tracking and CareTeam messaging
  3. Verify insurance and shipping details during the enrollment call
  4. Choose delivery method: Home delivery or pickup at CVS retail locations

Specialty Expedite™ Process

CVS Specialty's automated system can process many Isturisa prescriptions in as little as 3 days through EHR integration. This eliminates traditional phone calls and paperwork for 50% of specialty prescriptions.

What happens automatically:

  • Benefits verification and prior authorization status check
  • Patient profile creation with insurance details
  • Prescription processing and shipping coordination
From our advocates: "We've seen patients get their first Isturisa shipment within a week when their endocrinologist uses the CVS Specialty enrollment forms and the patient creates their online account immediately. The key is staying proactive with communication and having all your surgical records ready."

Appeals Process: Internal and External Review

Internal Appeals with Aetna

If your initial prior authorization is denied, you have 180 days from the denial notice to file an internal appeal.

Submit your appeal:

  • Online: Through your Aetna member portal (fastest)
  • Phone: Call member services (number on your ID card)
  • Mail: Include denial letter and supporting documentation

Timeline expectations:

  • Standard review: 30 days for decision
  • Expedited review: 72 hours if health is jeopardized

Virginia External Review Process

If Aetna upholds the denial after internal appeal, Virginia law provides an independent external review through the State Corporation Commission Bureau of Insurance.

Key deadlines:

  • 120 days from final internal denial to request external review
  • 45 days for standard external review decision
  • 72 hours for expedited external review

Required form: Virginia SCC Form 216-A (External Review Request)

Contact for guidance: 1-877-310-6560 (SCC Bureau of Insurance Consumer Services)

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters, identifies the specific denial basis, and drafts point-by-point rebuttals aligned to Aetna's own coverage policies, helping patients navigate complex specialty drug appeals more effectively.

Support Lines and Who to Call

Key Phone Numbers

Need Number Hours What to Ask
Member Services Number on your Aetna ID card 24/7 Coverage verification, claim status
Prior Authorization 1-855-240-0535 M-F 8AM-6PM CT PA status, requirements, expedited requests
CVS Specialty CareTeam 1-800-237-2767 M-F 8AM-6PM, 24/7 urgent Prescription status, side effects, dosing questions
Virginia SCC Bureau 1-877-310-6560 M-F business hours External review guidance, complaint filing

What to Ask When You Call

For PA status calls:

  • "What's the current status of prior authorization request [confirmation number]?"
  • "What additional documentation is needed for approval?"
  • "Can this be processed as expedited due to medical urgency?"

For denials:

  • "What specific criteria wasn't met in the denial?"
  • "What evidence would overturn this decision?"
  • "How do I request a peer-to-peer review with my endocrinologist?"

Virginia State Resources and External Review

Virginia provides robust consumer protections for health insurance appeals, especially valuable for specialty medications like Isturisa.

Virginia's External Review Advantages

  • Independent clinical review by board-certified specialists
  • No cost to patients for the review process
  • Binding decisions on insurance companies when appeals are approved
  • Expedited process for urgent medical needs

Additional Virginia Resources

Virginia Managed Care Ombudsman

  • Phone: 1-800-552-5019
  • Email: [email protected]
  • Assists with HMO and managed care plan issues

Virginia Poverty Law Center Health Assistance

  • Provides legal help for complex insurance appeals
  • Especially helpful for Medicaid and ACA marketplace issues
Note: Virginia's external review process has successfully overturned many wrongful specialty drug denials. The state's commitment to independent clinical review means your case will be evaluated by physicians familiar with rare diseases like Cushing's syndrome.

Common Denial Reasons and How to Fix Them

Denial Reason Required Evidence to Overturn Where to Get It
"Not medically necessary" Updated cortisol labs, functional impairment documentation, endocrinologist letter Your endocrinologist's office
"Surgery not attempted" Surgical records showing failure, or contraindication documentation Hospital records, surgeon's notes
"Non-formulary drug" Medical necessity letter explaining why alternatives failed or are contraindicated Endocrinologist with treatment history
"Experimental treatment" FDA approval documentation, clinical guidelines supporting use FDA Orange Book, medical literature
"Quantity limits exceeded" Weight-based dosing calculations, pharmacokinetic studies Prescriber calculations, manufacturer dosing guidelines

Medical Necessity Letter Template

Your endocrinologist should address these key points:

  1. Patient's specific diagnosis with ICD-10 code and lab confirmation
  2. Surgical history - what was attempted and why it failed
  3. Current symptoms and functional impairment
  4. Why Isturisa is medically necessary over alternatives
  5. Monitoring plan for safety and efficacy

FAQ: Your Most Common Questions

How long does Aetna prior authorization take for Isturisa in Virginia? Standard processing is 30-45 days, but expedited requests can be decided within 72 hours if your doctor certifies that waiting could jeopardize your health.

What if Isturisa is not on Aetna's formulary? You can request a formulary exception with medical necessity documentation. Many non-formulary specialty drugs are approved when proper evidence is provided.

Can I appeal if I live in Virginia but have coverage from another state? If your Aetna plan was issued in Virginia, you can use Virginia's external review process. Self-funded employer plans may have different rules - check with the SCC Bureau of Insurance.

Does step therapy apply to Isturisa? Aetna typically requires documentation that surgery was attempted or contraindicated before approving Isturisa. Alternative medications may need to be tried first unless contraindicated.

How much will Isturisa cost with Aetna coverage? Costs vary by plan, but specialty medications often have copays of $50-200+ per month. Check with CVS Specialty about manufacturer copay assistance programs.

What happens if my appeal is denied? After exhausting Aetna's internal appeals, you can request external review through Virginia's SCC Bureau of Insurance. Their decision is binding on Aetna.

Can I get Isturisa from a regular pharmacy? No, Isturisa is typically only available through specialty pharmacies like CVS Specialty due to its complex monitoring requirements and limited distribution.

How do I know if my request was expedited? Expedited requests require physician certification that standard timing could jeopardize your health. Ask your doctor to specifically request expedited review in their prior authorization submission.

Getting Isturisa approved by Aetna in Virginia requires careful documentation and persistence, but Virginia's strong consumer protections and external review process provide multiple pathways to coverage. When insurance companies understand the medical necessity and regulatory approval of treatments for rare conditions like Cushing's disease, approval rates improve significantly.

For complex cases requiring targeted appeal strategies, Counterforce Health helps patients and clinicians turn denials into evidence-backed appeals that address specific payer criteria and improve approval outcomes.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult your healthcare provider and insurance company for guidance specific to your situation. For assistance with insurance appeals and coverage issues in Virginia, contact the State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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