By Counterforce Health Team in Isturisa (osilodrostat) —

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

Quick Answer: Getting Isturisa (Osilodrostat) Covered by Aetna CVS Health in Washington

Aetna CVS Health requires prior authorization for Isturisa (osilodrostat) in Washington. The fastest path to approval: (1) Verify your endocrinologist has documented Cushing's disease with failed/contraindicated surgery, (2) Complete Aetna's specialty medication prior authorization form via fax (1-877-269-9916) or Availity portal, and (3) Include comprehensive clinical documentation showing medical necessity. If denied, you have 180 days to appeal internally, followed by Washington state's Independent Review Organization (IRO) external review process through the Office of the Insurance Commissioner.

First step today: Download the current Aetna prior authorization form for Isturisa and gather your surgical history, cortisol labs, and endocrinologist notes.

Table of Contents

Verify Your Plan and Find the Right Forms

Before starting your Isturisa (osilodrostat) prior authorization, confirm your specific Aetna plan details. Not all Aetna plans have identical formulary coverage or prior authorization requirements.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Isturisa prescriptions Aetna Precertification Lists Aetna
Formulary Status Specialty tier medication Member portal or formulary document Aetna
Step Therapy Surgery must be attempted first or contraindicated Medical policy bulletin Aetna Medical Policies
Prescriber Requirement Endocrinologist or qualified specialist preferred Prior authorization form Aetna
Diagnosis Documentation Confirmed Cushing's disease with supporting labs Clinical notes and test results FDA indication
Tip: Call the member services number on your insurance card to confirm your plan's specific formulary tier for Isturisa and any unique requirements.

Required Forms for Prior Authorization

Aetna CVS Health uses specific prior authorization forms for specialty medications like Isturisa. The form must be completed by your prescribing physician and include comprehensive clinical documentation.

Essential Documentation Checklist

Required Clinical Information:

  • Confirmed diagnosis of Cushing's disease (ACTH-secreting pituitary adenoma)
  • Documentation of failed pituitary surgery or medical contraindication to surgery
  • Baseline cortisol measurements (24-hour urine free cortisol, late-night salivary cortisol, or dexamethasone suppression test)
  • Previous treatments attempted and their outcomes
  • Current symptoms and functional impairment
  • Proposed dosing plan (typically starting at 2 mg twice daily)

Forms and Submission Methods:

Note: Over 95% of eligible authorizations are processed within 24 hours when complete documentation is provided, according to Aetna's streamlined review process.

Submission Portals and Methods

For Healthcare Providers

Availity Portal (preferred method):

  • Fastest processing for complete submissions
  • Real-time status updates
  • Integrated with many EHR systems
  • Access at availity.com (requires provider registration)

Fax Submission:

  • Fax number: 1-877-269-9916
  • Include cover sheet with patient demographics
  • Confirm receipt with follow-up call if urgent

For Patients and Families

Aetna Member Portal:

  • Check prior authorization status
  • Submit appeals if denied
  • Access formulary information
  • Available through aetna.com member login

Phone Support:

  • Member services: Number on your insurance card
  • Provider services: 1-855-240-0535
  • Urgent requests can be flagged during phone submission

CVS Specialty Pharmacy Onboarding

Isturisa is typically dispensed through CVS Specialty Pharmacy once prior authorization is approved. The onboarding process requires specific steps and documentation.

Step-by-Step Onboarding Process

  1. Enrollment Form Completion
  2. Benefits Verification
    • CVS Specialty automatically verifies insurance benefits
    • Patient copay and coverage details confirmed
    • Prior authorization status checked
  3. Prescription Transfer (if applicable)
    • Request transfer from current pharmacy
    • Provide CVS Specialty with current pharmacy information
    • Allow 3-7 business days for complete transfer
  4. Patient Communication Setup
    • Opt-in for text/email status updates
    • Confirm shipping address and preferences
    • Schedule initial consultation call
From our advocates: "Patients who complete the CVS Specialty enrollment form thoroughly and respond quickly to benefit verification calls typically receive their first Isturisa shipment within 7-10 days of prior authorization approval. Having insurance cards and previous pharmacy information ready speeds up the process significantly."

Support Lines and Contact Information

Member Support

  • Aetna Member Services: Use the number on your insurance card
  • CVS Specialty Pharmacy: 1-800-237-2767
  • Prescription status and refills: Available through member portals

Provider Support

  • Aetna Provider Services: 1-855-240-0535
  • Prior Authorization Status: Availity portal or phone
  • Peer-to-Peer Reviews: Request through provider services when PA is initially denied

What to Ask When Calling

  • Current prior authorization status
  • Required additional documentation
  • Timeline for decision
  • Appeal process if denied
  • Expedited review criteria for urgent cases

Washington State Appeals and External Review

Washington state provides strong consumer protections for insurance denials, including access to independent external review through certified Independent Review Organizations (IROs).

Appeals Timeline and Process

Appeal Level Timeline How to Submit Decision Time
Internal Appeal (Level 1) 180 days from denial Aetna member portal or written request 30-45 days standard, 72 hours expedited
Internal Appeal (Level 2) After Level 1 denial Same methods 30-45 days standard
External IRO Review 180 days from final internal denial Through Aetna to Washington OIC 20 days standard, 72 hours expedited

Washington External Review Process

Eligibility: After exhausting Aetna's internal appeals, Washington residents can request external review for medical necessity denials, experimental/investigational determinations, or coverage disputes.

How to Request:

  1. Submit external review request form to Aetna
  2. Aetna forwards case to Washington Office of Insurance Commissioner
  3. OIC assigns certified IRO with relevant expertise
  4. You have 5 business days to submit additional information to the IRO

IRO Decision Standards:

  • Must use current medical and scientific evidence
  • Can override Aetna's coverage standards if found unreasonable
  • Decision is binding on both parties
Important: The Washington Office of Insurance Commissioner provides consumer assistance at 1-800-562-6900 and can help navigate the external review process.

Common Denial Reasons and Solutions

Understanding why Aetna might initially deny Isturisa coverage helps you prepare a stronger prior authorization or appeal.

Denial Reasons and Fixes

Common Denial Reason Required Documentation to Overturn
"Not medically necessary" Detailed endocrinologist notes showing Cushing's disease diagnosis with supporting lab values
"Surgery not attempted" Documentation of surgical failure, contraindication, or high-risk status
"Prescriber not qualified" Prescription from endocrinologist or documentation of specialist referral/consultation
"Insufficient prior therapy" Records showing previous medical management attempts or surgical intervention
"Non-formulary medication" Formulary exception request with clinical justification

Medical Necessity Letter Components

For clinicians preparing appeals, include these evidence-based elements:

  • Diagnosis confirmation: ICD-10 codes, lab results (elevated 24-hour urine free cortisol, abnormal dexamethasone suppression test)
  • Surgical history: Documentation of transsphenoidal surgery attempt with outcome, or medical contraindication to surgery
  • Clinical rationale: FDA-approved indication for Cushing's disease, citing Isturisa prescribing information
  • Monitoring plan: Regular cortisol monitoring, electrolyte management, QT interval surveillance

Costs and Patient Assistance

Isturisa is a high-cost specialty medication, but several assistance programs can help reduce out-of-pocket expenses.

Financial Assistance Options

Manufacturer Support:

Foundation Grants:

  • National Organization for Rare Disorders (NORD) assistance
  • HealthWell Foundation grants for rare disease medications
  • Patient Access Network Foundation programs

State Programs:

  • Washington Apple Health (Medicaid) for eligible individuals
  • Washington Prescription Drug Program for additional coverage options
Note: Copay assistance programs typically cannot be combined with government insurance (Medicare, Medicaid) but may help patients with commercial Aetna plans.

At Counterforce Health, we help patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed letters that address specific payer criteria. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with the insurer's own rules, incorporating the right clinical evidence and procedural requirements to maximize approval chances.

FAQ

How long does Aetna CVS Health prior authorization take for Isturisa in Washington? Standard prior authorization decisions are typically made within 24-48 hours for complete submissions. Complex cases may take up to 14 days. Expedited reviews for urgent medical situations are completed within 72 hours.

What if Isturisa is non-formulary on my Aetna plan? You can request a formulary exception by demonstrating medical necessity and providing clinical documentation. Your endocrinologist must show that formulary alternatives are inappropriate or contraindicated for your specific case.

Can I request an expedited appeal if Aetna denies my Isturisa prior authorization? Yes, if delaying treatment could seriously jeopardize your health or cause severe symptoms. Contact Aetna member services to request expedited review, which must be completed within 72 hours.

Does step therapy apply if I've already had surgery outside of Washington? No, step therapy requirements are based on your individual medical history, not your location. Provide documentation of previous surgical intervention regardless of where it occurred.

What happens if the Washington IRO upholds Aetna's denial? You can file a complaint with the Washington Office of Insurance Commissioner for further review. Additionally, you may have legal options, though the IRO decision is typically the final step in the appeals process.

How do I know if my endocrinologist is considered "qualified" by Aetna? Aetna generally accepts prescriptions from board-certified endocrinologists. If your prescriber is not an endocrinologist, they should document consultation with an endocrine specialist or provide detailed justification for their expertise in managing Cushing's disease.

Can I use CVS retail pharmacies instead of CVS Specialty for Isturisa? No, Isturisa is classified as a specialty medication and must be dispensed through CVS Specialty Pharmacy or another approved specialty pharmacy in Aetna's network.

Sources and Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice and should not replace consultation with your healthcare provider. Insurance policies and state regulations may change. For the most current information, contact your insurer directly and consult with qualified medical professionals. Washington residents can get free assistance with insurance appeals through the Office of the Insurance Commissioner at 1-800-562-6900.

For personalized help with your Isturisa appeal, Counterforce Health provides expert assistance in crafting evidence-based appeal letters that address specific payer criteria and maximize your chances of approval.

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