By Counterforce Health Team in Isturisa (osilodrostat) —

How to Get Isturisa (Osilodrostat) Covered by Blue Cross Blue Shield in Michigan: Complete Prior Authorization and Appeal Guide

Quick Answer: Getting Isturisa Approved by Blue Cross Blue Shield in Michigan

Isturisa (osilodrostat) requires prior authorization from Blue Cross Blue Shield of Michigan for adult Cushing's disease patients. Your fastest path to approval: 1) Gather documented hypercortisolism via two positive tests (24-hour UFC, late-night salivary cortisol, or 1mg dexamethasone suppression test), 2) Submit PA request through BCBSM provider portal with endocrinologist prescription and surgical history, 3) If denied, file internal appeal within plan deadlines, then external review with Michigan DIFS within 127 days. Start by calling the number on your member ID card to confirm your plan's specific requirements.

Table of Contents

Understanding BCBS Michigan's Isturisa Requirements

Blue Cross Blue Shield of Michigan (BCBSM) covers Isturisa (osilodrostat) as a specialty medication for adult Cushing's disease when pituitary surgery isn't an option or hasn't been curative. As the state's dominant insurer covering about 67% of commercial plan members, BCBSM follows strict prior authorization protocols for this high-cost oral cortisol synthesis inhibitor.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required before dispensing BCBSM Provider Portal
Prescriber Endocrinologist preferred Plan-specific PA criteria
Diagnosis Documentation 2+ positive cortisol tests Endocrine Society Guidelines
Surgical History Documentation of contraindication/failure Medical records required
Appeals Deadline 127 days for external review Michigan DIFS

The medication works by blocking 11β-hydroxylase, reducing cortisol production in patients with confirmed Cushing's disease. BCBSM typically requires documentation of failed or contraindicated pituitary surgery before approving this oral alternative.

Step-by-Step: Fastest Path to Approval

1. Confirm Your Cushing's Disease Diagnosis

Who: Your endocrinologist
Timeline: 2-4 weeks for complete workup

You'll need at least two abnormal first-line tests showing hypercortisolism:

  • 24-hour urinary free cortisol (UFC): >50-100 mcg/24h
  • Late-night salivary cortisol: Elevated above normal range
  • 1mg overnight dexamethasone suppression test: Serum cortisol >1.8 mcg/dL
Tip: Multiple collections improve accuracy. BCBSM often denies requests with only one positive test.

2. Document Surgical Status

Who: Your endocrinologist and surgeon (if applicable)
Timeline: Immediate if records exist

BCBSM requires clear documentation that pituitary surgery is either:

  • Not feasible due to tumor location/patient factors
  • Previously attempted but not curative
  • Contraindicated due to medical comorbidities

3. Submit Prior Authorization Request

Who: Your prescriber's office
Timeline: 5-7 business days for standard review

Your endocrinologist submits through the BCBSM provider portal or via fax. The request must include:

  • Complete medical history and physical exam findings
  • Laboratory results (cortisol tests, ACTH levels)
  • Imaging studies (pituitary MRI, CT adrenals)
  • Documentation of surgical consultation/contraindication
  • Treatment goals and monitoring plan

4. Track Your Request Status

Who: You and your prescriber's office
Timeline: Check after 3-5 business days

Monitor approval status through your provider's portal or by calling BCBSM member services. Urgent cases can be expedited with physician justification.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
Insufficient diagnostic evidence Submit additional cortisol testing 2+ abnormal UFC/salivary/DST results
Missing surgical evaluation Provide neurosurgical consultation Letter stating contraindication/failure
Non-endocrinologist prescriber Transfer care or get co-signature Endocrinology consultation note
Incomplete prior therapy documentation Document failed alternatives Records of ketoconazole, pasireotide trials
Medical necessity unclear Strengthen clinical justification Detailed symptom progression, QOL impact

When Counterforce Health analyzes Isturisa denials, we commonly see missing surgical documentation as the primary issue. BCBSM wants clear evidence that surgery isn't the first-line option before approving this oral therapy.

Appeals Process in Michigan

Internal Appeal with BCBSM

Timeline: File within plan-specified deadline (typically 60 days)
Decision: 30 days for pre-service, 60 days post-service

Submit additional clinical evidence addressing the specific denial reason. Include:

  • Updated laboratory values
  • Peer-reviewed literature supporting off-label use
  • Physician letter emphasizing medical necessity
  • Patient impact statement

External Review with Michigan DIFS

Timeline: File within 127 days of final internal denial
Decision: Up to 60 days (72 hours if expedited)

Michigan's Department of Insurance and Financial Services offers independent medical review through contracted organizations. File using Form FIS 0018 or call 877-999-6442.

Required for external review:

  • Final denial letter from BCBSM
  • All medical records supporting the request
  • Completed external review application
  • Physician statement (for expedited review)
From our advocates: We've seen Michigan external reviews overturn BCBSM denials when strong endocrinology support and comprehensive cortisol testing documentation are provided. The independent medical experts often favor evidence-based specialty care recommendations over initial utilization management decisions.

Patient Support and Cost Assistance

Recordati's R.A.R.E. Patient Support Program

Isturisa is exclusively available through Recordati Rare Diseases' comprehensive support program:

  • Copay Support: $20 copay for eligible commercially insured patients
  • Financial Assistance: Needs-based support for uninsured/underinsured patients
  • Insurance Appeals: Pre-written letter templates and specialist support
  • Specialty Pharmacy: Direct fulfillment through Anovo Specialty Rx

Contact: 1-888-855-RARE (7273), Monday-Friday 8 AM-8 PM ET

Additional Foundation Support

  • HealthWell Foundation: Up to $10,000-$15,000 annually for Cushing's patients
  • PAN Foundation: Up to $11,600 yearly copay assistance
  • Patient Advocate Foundation: Case management and appeals assistance

Healthcare coverage challenges are complex, and Counterforce Health specializes in turning insurance denials into successful appeals by analyzing payer policies and crafting evidence-based rebuttals that align with plan-specific requirements.

When to Escalate

Contact Michigan DIFS

If BCBSM's internal appeals process seems unfair or delayed, file a complaint with Michigan's insurance regulator:

Michigan Department of Insurance and Financial Services
Phone: 877-999-6442
Online: michigan.gov/difs
Mail: P.O. Box 30220, Lansing, MI 48909-7720

For cases involving:

  • Repeated inappropriate denials
  • Failure to follow Michigan insurance law
  • Urgent medical situations with delayed approvals

Contact the State Bar of Michigan's lawyer referral service or patient advocacy organizations for specialized healthcare law attorneys.

Frequently Asked Questions

How long does BCBS Michigan prior authorization take for Isturisa?
Standard requests: 5-7 business days. Urgent requests with physician justification: 24-48 hours. Submit through the provider portal for fastest processing.

What if Isturisa isn't on my BCBS formulary?
Request a formulary exception through your prescriber. Include clinical justification for why formulary alternatives (ketoconazole, pasireotide) aren't appropriate for your case.

Can I get an expedited appeal if my Cushing's symptoms are worsening?
Yes. Your physician must provide written documentation that delays would seriously jeopardize your health. Michigan DIFS offers 72-hour expedited external reviews.

Do I need to try other medications first (step therapy)?
BCBSM may require documentation of contraindications or failures with alternatives like ketoconazole or pasireotide LAR. Surgical evaluation is typically required first.

What happens if Michigan external review denies my appeal?
You can request a state fair hearing within 120 days of the external review denial, though options become more limited at this stage.

Does BCBS cover Isturisa for other conditions besides Cushing's disease?
Coverage is FDA-indication specific. Off-label use for other hypercortisolism conditions requires strong clinical justification and literature support.

Checklist: What to Gather Before You Start

Before submitting your Isturisa prior authorization:

  • Insurance card with member ID and group number
  • Complete endocrinology consultation notes
  • Laboratory results: 2+ abnormal cortisol tests
  • Pituitary MRI and adrenal imaging
  • Neurosurgical consultation (if applicable)
  • Documentation of failed/contraindicated alternatives
  • Current medication list and allergies
  • Prescriber's NPI and contact information

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions vary by individual plan and medical circumstances. Always consult with your healthcare provider and insurance plan directly for personalized guidance. Coverage policies and appeal procedures may change; verify current requirements with official sources.

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