By Counterforce Health Team in Isturisa (osilodrostat) —

How to Get Isturisa (Osilodrostat) Covered by Cigna in North Carolina: Complete Prior Authorization Guide

Answer Box: Getting Isturisa (Osilodrostat) Covered by Cigna in North Carolina

Eligibility: Cigna covers Isturisa for adult Cushing's disease when surgery isn't an option or wasn't curative, prescribed by an endocrinologist with documented abnormal cortisol tests.

Fastest path: Submit prior authorization through Cigna's provider portal with diagnosis confirmation, surgical history, and specialist notes. Standard review takes 72 hours.

First step today: Contact your endocrinologist to gather cortisol test results, surgical consultation notes, and have them initiate the PA request through Accredo specialty pharmacy.

Table of Contents

  1. Plan Types & Coverage Implications
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Process
  5. Cost-Share Basics
  6. Common Approval Patterns
  7. Appeals Process in North Carolina
  8. When to Use Smart NC External Review
  9. FAQ

Plan Types & Coverage Implications

Cigna's HMO, PPO, and EPO plans in North Carolina all cover specialty drugs like Isturisa, but with different network and referral requirements:

  • HMO Plans: Require Primary Care Physician coordination and referrals to endocrinologists. Generally lowest costs but most restrictive network.
  • PPO Plans: Broadest network flexibility, no referral needed for specialists, but higher out-of-pocket costs.
  • EPO Plans: Must use network providers (except emergencies), moderate flexibility and costs.

All plan types place Isturisa in the specialty drug tier with prior authorization requirements and typically require dispensing through Accredo specialty pharmacy.

Formulary Status & Tier Placement

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Approval needed before dispensing Required for all plans Cigna PA Policy
Formulary Tier Tier 5 (Specialty) Check myCigna drug list Drug List Search
Step Therapy May require trying alternatives first Plan-specific Verify with current policy
Quantity Limits Typically 30-day supply Standard for specialty drugs Accredo Guidelines
Specialist Requirement Endocrinologist must prescribe All coverage policies PA Criteria

Isturisa is classified as a non-formulary specialty medication on most Cigna plans, meaning it requires both prior authorization and formulary exception approval.

Prior Authorization Requirements

Step-by-Step: Fastest Path to Approval

  1. Gather Diagnostic Documentation (Patient/Clinic)
    • Abnormal cortisol tests: UFC, late-night salivary cortisol, or dexamethasone suppression test
    • Timeline: Same day
    • Submit via Cigna portal
  2. Document Surgical History (Endocrinologist)
    • Surgical consultation showing contraindication OR post-surgical failure
    • Timeline: 1-2 days
    • Include in PA submission
  3. Complete PA Form (Prescriber)
  4. Submit Through Accredo (Clinic)
    • Coordinate with specialty pharmacy for PA processing
    • Timeline: 1 day
    • Phone: 1-800-803-2523
  5. Await Standard Review (Cigna)
    • Decision within 72 hours of complete submission
    • Expedited review available if urgent (24 hours)
    • Track through myCigna portal
  6. Address Any Requests (Clinic/Patient)
    • Respond to additional information requests within 48 hours
    • Timeline: 1-2 days
    • Maintain documentation copies
  7. Begin Treatment or Appeal (Patient)
    • If approved, coordinate delivery through Accredo
    • If denied, initiate appeal process immediately
    • Timeline: Begin within 180 days of denial

Specialty Pharmacy Process

Isturisa must be dispensed through Accredo, Cigna's specialty pharmacy partner. Here's how the process works:

Patient Setup Steps:

  • Your endocrinologist sends the prescription to Accredo
  • Accredo contacts you to verify insurance and shipping details
  • They coordinate the prior authorization with your doctor
  • Once approved, medication ships to your home at no extra cost

Key Accredo Services:

  • Prior authorization coordination
  • Insurance benefit verification
  • Copay assistance program enrollment
  • Clinical support and monitoring
  • Home delivery with temperature control
Tip: Register for MyAccredoPatients portal to track your prescription status and communicate directly with your care team.

Cost-Share Basics

As a Tier 5 specialty drug, Isturisa typically involves coinsurance rather than a fixed copay. Common cost-sharing structures include:

  • Specialty Tier Coinsurance: Often 25-50% of drug cost after deductible
  • Monthly Out-of-Pocket: Can range from hundreds to over $1,000 depending on your plan
  • Annual Out-of-Pocket Maximum: Protects against unlimited costs

Savings Options to Explore:

Note: This is educational information only. Consult your plan documents for exact cost-sharing details.

Common Approval Patterns

What Strong Submissions Include:

Medical Necessity Letter Checklist

  • Problem Statement: Clear diagnosis of endogenous Cushing's disease with ICD-10 code E24.0
  • Prior Treatments: Documentation of surgical consultation and outcome/contraindication
  • Clinical Rationale: Why Isturisa is medically necessary for this specific patient
  • Guideline Citations: Reference to FDA labeling and endocrine society guidelines
  • Dosing Plan: Starting dose (2 mg BID) and titration protocol
  • Monitoring Plan: Lab monitoring for hypocortisolism and QT prolongation

Supporting Documentation

  • Laboratory results confirming hypercortisolemia
  • Surgical consultation notes or contraindication documentation
  • Previous treatment history and outcomes
  • Specialist credentials (endocrinologist or Cushing's specialist)

Appeals Process in North Carolina

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documents
Prescriber not specialist Submit endocrinologist credentials Specialist verification form
Incomplete diagnosis documentation Provide comprehensive lab results UFC, salivary cortisol, DST results
Surgery not documented as failed/contraindicated Submit surgical consultation Operative notes or contraindication letter
Step therapy not completed Document prior treatment failures Treatment history with outcomes

Internal Appeals Timeline:

  • First Level: 180 days from denial to file
  • Decision: Within 30 days for standard, 72 hours for expedited
  • Second Level: Additional 60 days if first level denied
  • Peer-to-Peer: Request endocrinologist review during appeal

Contact Information:

  • Phone: 1-800-882-4462
  • Fax: 1-866-873-8279
  • Portal: myCigna member portal

When to Use Smart NC External Review

If Cigna's internal appeals fail, North Carolina offers free external review through Smart NC:

Eligibility Requirements:

  • Exhausted Cigna's internal appeal process (or qualify for expedited waiver)
  • Denial based on medical necessity or experimental treatment determination
  • State-regulated plan (not self-funded employer plans unless opted in)

How to File:

  1. Contact Smart NC: Call 1-855-408-1212 for guidance
  2. Submit Request: Use external review form from NC Department of Insurance
  3. Provide Documentation: Include all medical records, denial letters, and appeal responses
  4. Timeline: 45 days for standard review, 72 hours for expedited

Smart NC Advantages:

  • Free advocacy support to help prepare your case
  • Independent medical review by specialists
  • Binding decision on insurance company
  • Fast turnaround for urgent cases (24-72 hours)
From our advocates: "We've seen several Cushing's disease cases succeed at external review in North Carolina when patients provided comprehensive endocrine testing results and clear documentation that surgery wasn't viable. The key is presenting a complete clinical picture that demonstrates medical necessity."

Counterforce Health Support

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to craft targeted, evidence-backed rebuttals. For complex cases like Isturisa coverage, the platform identifies specific denial reasons and drafts point-by-point responses aligned to Cigna's own coverage rules, pulling the right clinical evidence and procedural requirements for North Carolina's appeal process.

FAQ

How long does Cigna prior authorization take for Isturisa in North Carolina? Standard review takes 72 hours from complete submission. Expedited review (for urgent medical need) takes 24 hours.

What if Isturisa is non-formulary on my Cigna plan? You can request a formulary exception by providing clinical documentation that preferred alternatives are contraindicated or ineffective. This is submitted along with the prior authorization.

Can I request an expedited appeal if denied? Yes, if the delay would seriously jeopardize your health. Expedited appeals receive decisions within 72 hours. Your endocrinologist must certify the urgent medical need.

Does step therapy apply if I failed treatments outside North Carolina? Yes, treatment failures from other states count toward step therapy requirements. Provide documentation of prior therapies tried and their outcomes.

What's the difference between Cigna's internal appeal and Smart NC external review? Internal appeals are reviewed by Cigna staff. External review through Smart NC uses independent medical experts and provides a binding decision that Cigna must follow.

How much does external review cost in North Carolina? External review through Smart NC is completely free to consumers. There are no filing fees or costs for the independent medical review.

Sources & Further Reading

Disclaimer: This information is educational and not medical or legal advice. Coverage policies and procedures may change. Always verify current requirements with Cigna and consult healthcare providers for medical decisions. For personalized assistance with North Carolina insurance appeals, contact Smart NC at 1-855-408-1212.

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