By Counterforce Health Team in Isturisa (osilodrostat) —

How to Get Isturisa (Osilodrostat) Covered by Cigna in New York: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Isturisa Covered by Cigna in New York

Fastest path to approval: Submit prior authorization through CoverMyMeds with endocrinologist consultation, confirmed Cushing's syndrome diagnosis, and surgical history documentation. If denied, you have 180 days for internal appeal, then 4 months for New York DFS external review—which has strong patient protections and high overturn rates for well-documented rare disease appeals.

Start today: Verify your Cigna plan includes Accredo specialty pharmacy, gather your Cushing's syndrome diagnostic tests (UFC, salivary cortisol), and contact your endocrinologist to initiate the PA request.

Table of Contents

  1. Verify Your Cigna Plan Coverage
  2. Prior Authorization Requirements
  3. Step-by-Step: Fastest Path to Approval
  4. Forms and Submission Portals
  5. Specialty Pharmacy Setup (Accredo)
  6. Common Denial Reasons & Solutions
  7. Appeals Process in New York
  8. Support Resources and Contact Information
  9. FAQ

Verify Your Cigna Plan Coverage

Before starting your Isturisa prior authorization, confirm your plan details through the myCigna portal or call member services at 1-800-882-4462. Key information to verify:

  • Specialty pharmacy benefit: Most Cigna plans require specialty drugs like Isturisa to be dispensed through Accredo
  • Prior authorization requirements: Confirm PA is needed (it typically is for Isturisa)
  • Formulary status: Check if Isturisa is covered on your plan's formulary tier
Note: Beginning January 1, 2026, most specialty prescriptions will be automatically transferred to Accredo pharmacy for eligible Cigna plans.

Prior Authorization Requirements

Cigna requires prior authorization for Isturisa (osilodrostat) when treating Cushing's syndrome. According to Cigna's coverage policy, coverage is approved when:

Coverage Criteria

  • Prescriber requirement: Medication prescribed by or in consultation with an endocrinologist or physician specializing in endogenous Cushing's syndrome treatment
  • Diagnosis confirmation: Confirmed diagnosis of endogenous Cushing's syndrome with appropriate biochemical testing

Medical Necessity Documentation Needed

  • Elevated 24-hour urine free cortisol (UFC) or elevated late-night salivary cortisol
  • Abnormal dexamethasone suppression test results
  • Documentation of surgical history or contraindications to surgery
  • Prior medication trials and outcomes (if applicable)

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient/Clinic)

Timeline: 1-2 business days
Documents needed:

  • Insurance card with Cigna member ID
  • Confirmed Cushing's syndrome diagnosis with lab results
  • Surgical consultation notes or contraindication documentation
  • Complete medication history

2. Endocrinologist Consultation (Patient)

Timeline: Variable based on scheduling
Action: Ensure your prescriber is an endocrinologist or has documented consultation with one, as this is a strict Cigna requirement.

3. Submit Prior Authorization (Clinic Staff)

Timeline: Same day submission
Method: Use CoverMyMeds for fastest processing (35% faster than fax/phone)
Alternative: Call 1-800-882-4462 for urgent cases

4. Track Application Status (Patient/Clinic)

Timeline: Check within 2-3 business days
Method: Monitor through myCigna portal or CoverMyMeds dashboard
Expected response: 5 business days for standard review

5. Set Up Accredo if Approved (Patient)

Timeline: 1-2 business days after approval
Action: Call Accredo at 877-826-7657 to complete enrollment and coordinate first shipment

Forms and Submission Portals

CoverMyMeds - Fastest option with real-time tracking:

SureScripts - For EHR integration:

  • Submit directly through your electronic health record system
  • Real-time eligibility verification

Alternative Submission Methods

Phone Submission (Urgent cases):

  • Number: 1-800-882-4462
  • Have patient Cigna ID and clinical documentation ready
  • Request verbal confirmation and reference number

Fax Submission:

  • Number: 1-855-840-1678 (verify current number)
  • Include completed PA form and all supporting documentation
  • Retain fax confirmation for records

Specialty Pharmacy Setup (Accredo)

Isturisa requires dispensing through Cigna's specialty pharmacy network, primarily Accredo. Here's how to set up your prescription:

Enrollment Process

  1. Contact Accredo: Call 877-826-7657 after PA approval
  2. Complete intake: Provide insurance information and prescription details
  3. Schedule delivery: Coordinate shipping (no additional cost, including temperature-controlled medications)
  4. Set up refills: Enable text refill reminders through myCigna app

Transfer from Retail Pharmacy

If you have an existing Isturisa prescription at a retail pharmacy:

  • Log into myCigna app and select "Transfer Prescriptions"
  • Or call Accredo directly to initiate transfer
  • Provide current pharmacy information and prescription details

Common Denial Reasons & Solutions

Denial Reason How to Fix Required Documentation
Prescriber not endocrinologist Obtain endocrinology consultation Consultation notes, referral letter
Insufficient diagnosis documentation Submit complete biochemical testing UFC results, salivary cortisol, DST
Missing surgical history Document surgical evaluation/contraindication Surgical consultation, medical contraindications
Step therapy not completed Document prior medication trials Previous treatment records, failure/intolerance notes
"Not medically necessary" Provide detailed clinical rationale Medical necessity letter with guidelines
From our advocates: We've seen Cushing's syndrome cases succeed on appeal when providers include specific cortisol levels, document why surgery isn't viable, and cite the FDA approval language. The key is showing Isturisa fits the patient's unique clinical picture rather than just listing general symptoms.

Appeals Process in New York

New York offers robust patient protections for specialty drug denials through a multi-level appeals process.

Internal Appeals with Cigna

Timeline: 180 days from denial date to file
Process: Submit through Cigna appeals portal or mail
Response time: 60 days for review, 75 days for notification
Required documents:

  • Original denial letter
  • Clinical records supporting medical necessity
  • Prescriber letter of support

New York State External Review

If your internal appeal is denied, New York's Department of Financial Services (DFS) offers independent external review with strong patient protections:

Key Benefits:

  • Independent medical experts review your case (not Cigna employees)
  • Binding decision on Cigna if approved
  • High success rates for well-documented rare disease appeals (50-70% overturn rate)
  • Expedited review available for urgent health needs

Timeline & Process:

  • Filing deadline: 4 months from Cigna's final denial
  • Standard review: 30 days for decision
  • Expedited review: 72 hours (24 hours for urgent drug denials)
  • Cost: $25 fee (waived for financial hardship or Medicaid; refunded if successful)

Required Documentation:

When to Request Expedited Review

Request expedited review if delays could seriously jeopardize your health, such as:

  • Uncontrolled cortisol levels causing severe complications
  • Rapid progression of Cushing's syndrome symptoms
  • Contraindications to alternative treatments

Support Resources and Contact Information

Patient Support Lines

  • Cigna Member Services: 1-800-882-4462
  • Accredo Specialty Pharmacy: 877-826-7657
  • Community Health Advocates (free NY insurance help): 888-614-5400

Provider Support

  • Cigna Provider Services: Access through CignaforHCP.com
  • Prior Authorization Status: CoverMyMeds portal or Cigna provider portal
  • Peer-to-Peer Review: Request through provider services for complex denials

Financial Assistance

  • Recordati Patient Assistance: Contact manufacturer directly for potential copay support programs
  • New York State Assistance: Community Health Advocates can help identify additional programs

For patients navigating complex insurance appeals, platforms like Counterforce Health specialize in turning insurance denials into evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft targeted rebuttals aligned with payer-specific requirements.

FAQ

How long does Cigna prior authorization take for Isturisa in New York?
Standard PA requests are processed within 5 business days. Urgent requests can be expedited by calling 1-800-882-4462.

What if Isturisa is not on my Cigna formulary?
Request a formulary exception through your prescriber with medical necessity documentation. If denied, you can appeal through Cigna's internal process and then New York's external review system.

Can I get expedited review if my Cushing's symptoms are severe?
Yes, both Cigna and New York DFS offer expedited reviews when delays could seriously jeopardize your health. Your physician must certify the urgent medical need.

Does step therapy apply if I tried other treatments outside New York?
Document all prior treatments with detailed records of failure or intolerance. New York external reviewers consider comprehensive treatment history regardless of where care was received.

What happens if my external appeal is denied in New York?
The external review decision is binding and final. However, you may have options to resubmit with additional evidence or explore other coverage pathways.

How much does Isturisa cost without insurance?
Isturisa pricing varies by strength and dose, typically in the high four- to five-figure range monthly. Contact Accredo or Recordati for specific pricing and patient assistance options.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies and procedures may change. Always verify current requirements with Cigna and consult your healthcare provider for medical decisions. For additional help with New York insurance appeals, contact Community Health Advocates at 888-614-5400 or visit the New York Department of Financial Services website.

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