By Counterforce Health Team in Isturisa (osilodrostat) —

How to Get Isturisa (Osilodrostat) Covered by Cigna in Ohio: Complete Cost Guide with Appeals Process

Answer Box: Getting Isturisa Covered by Cigna in Ohio

Isturisa (osilodrostat) requires prior authorization through Cigna's specialty pharmacy network (Accredo) and is typically covered on Tier 4/5 with high cost-sharing. Your endocrinologist must submit documentation proving Cushing's disease diagnosis, surgical history, and medical necessity. If denied, you have 180 days to file internal appeals, then external review through Ohio's Department of Insurance. Commercial patients may qualify for manufacturer copay assistance reducing costs to $20/month.

First step today: Contact your prescribing endocrinologist to initiate the prior authorization request through Cigna's provider portal or CoverMyMeds, ensuring all required clinical documentation is included.

Table of Contents

  1. What Drives Isturisa Costs
  2. Benefit Investigation Guide
  3. Manufacturer and Foundation Assistance
  4. Prior Authorization Requirements
  5. Appeals Process in Ohio
  6. Specialty Pharmacy Coordination
  7. Annual Planning and Renewals
  8. Conversation Scripts
  9. FAQ

What Drives Isturisa Costs

Isturisa's high cost stems from its classification as a specialty medication for the rare condition Cushing's disease. Understanding your benefit design helps you navigate the system effectively.

Cigna's Tiering Structure

Isturisa typically falls on Tier 4 (brand specialty) or Tier 5 (specialty tier) in most Cigna plans, meaning:

  • Highest cost-sharing tier with coinsurance rather than flat copays
  • Specialty pharmacy requirement through Accredo
  • 30-day supply limits with home delivery
  • Prior authorization mandatory before any coverage
Note: Your specific tier placement can vary by plan. Check your formulary at Cigna's drug list tool.

Cost Factors Beyond Tiering

  • Deductible application: Many plans apply specialty drugs to your medical deductible first
  • Out-of-pocket maximums: Specialty tier costs count toward your annual limit
  • Quantity limits: Standard 30-day supply; overrides require additional justification

Benefit Investigation Guide

Before starting treatment, gather this information from Cigna to avoid surprises:

Questions for Member Services

Call the number on your insurance card and ask:

  1. "Is Isturisa (osilodrostat) covered on my formulary, and what tier?"
  2. "What's my specialty drug coinsurance percentage and deductible?"
  3. "Do I need prior authorization, and are there step therapy requirements?"
  4. "Must I use Accredo specialty pharmacy?"
  5. "What's my out-of-pocket maximum for specialty drugs?"

Information to Record

  • Prior authorization requirements: Specific clinical criteria needed
  • Step therapy protocols: Alternative medications you must try first
  • Quantity limits: Standard supply and override process
  • Specialty pharmacy network: Accredo contact information
  • Appeal deadlines: Internal and external review timelines

Manufacturer and Foundation Assistance

Multiple programs can reduce your out-of-pocket costs significantly.

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

Commercial insurance patients may qualify for a $20 copay card through the manufacturer's assistance program.

Eligibility:

  • Must have commercial (private) insurance
  • Prescribed Isturisa by a healthcare provider
  • U.S. residency required

How to apply:

  1. Your doctor initiates enrollment by faxing a referral form
  2. Call the support hotline: 1-888-855-RARE (7273)
  3. Insurance specialist verifies benefits and copay card eligibility
  4. Pharmacy coordination through Anovo Specialty Pharmacy
Important: Medicare and Medicaid patients cannot use manufacturer copay cards but may qualify for other assistance programs.

National Foundation Support

Patient Access Network (PAN) Foundation:

  • $10,000 grant per 12-month cycle for Cushing's disease medications
  • Income limit: Up to 500% of federal poverty level ($77,500 for family of two)
  • Requirements: Must have some insurance coverage
  • Application: Quick online process at PAN Foundation

HealthWell Foundation:

  • Copayment assistance for insured patients
  • Income limit: 300-500% of federal poverty level
  • Coverage: Private insurance, Medicare, Medicaid accepted
  • Application: Online at HealthWell Foundation

Ohio-Specific Programs

Complex Medical Help (CMH) Program:

  • For Ohio residents under age 25 with special health needs
  • Eligibility: Under 200% federal poverty level or receiving Medicaid/SSI
  • Contact: 800-755-4769 or local county health department
  • Requirements: Care by CMH-approved physician

Prior Authorization Requirements

Cigna requires comprehensive documentation before approving Isturisa coverage.

Required Clinical Documentation

Your endocrinologist must submit:

Diagnosis Confirmation:

  • Abnormal 24-hour urinary free cortisol (UFC) levels
  • Elevated late-night salivary cortisol
  • Abnormal dexamethasone suppression test results
  • ICD-10 diagnosis code for Cushing's disease

Surgical History:

  • Documentation that pituitary surgery is not an option, OR
  • Proof that previous surgery was unsuccessful
  • Contraindications to surgical intervention

Prescriber Requirements:

  • Must be prescribed by an endocrinologist or specialist
  • Board certification in endocrinology preferred

Submission Process

Fastest methods:

  1. Electronic submission via Cigna provider portal
  2. CoverMyMeds platform for streamlined processing
  3. Phone: Provider services line on insurance card
  4. Fax: Submit to prior authorization department (verify current number)

Timeline expectations:

  • Standard requests: 72 hours for decision
  • Urgent requests: 24 hours when delay could jeopardize health

Appeals Process in Ohio

If Cigna denies your Isturisa prior authorization, Ohio provides multiple appeal levels.

Internal Appeals with Cigna

First-level internal appeal:

  • Deadline: 180 days from denial notice
  • Process: Submit written appeal with additional clinical documentation
  • Timeline: Cigna has 30 days to respond (expedited: 72 hours for urgent)

Second-level internal appeal:

  • Automatic right if first appeal denied
  • Timeline: Additional 30 days for Cigna's response
  • Requirements: New clinical evidence or expert opinion recommended

External Review Through Ohio

After exhausting internal appeals, Ohio residents can request independent external review.

Ohio Department of Insurance External Review:

  • Deadline: 180 days from final internal denial
  • Process: File request with your health plan, who notifies Ohio DOI
  • Cost: No charge to patient
  • Timeline: 30 days for standard review, 72 hours for expedited

How to file:

  1. Complete Ohio's External Review Request Form
  2. Submit to your insurance company (they forward to Ohio DOI)
  3. Include all medical records and denial letters
  4. Contact: Ohio Department of Insurance at 1-800-686-1526
Key advantage: Ohio's external review decisions are binding on Cigna – if overturned, they must cover your treatment.

Specialty Pharmacy Coordination

Cigna requires Isturisa to be dispensed through Accredo specialty pharmacy, not retail pharmacies.

Accredo Requirements

Mandatory for most Cigna plans:

  • All specialty medications must go through Accredo
  • 30-day supply limit standard
  • Home delivery required
  • Contact: 1-800-803-2523

Coordination Process

After prior authorization approval:

  1. Your doctor sends prescription directly to Accredo
  2. Accredo contacts you to verify insurance and shipping address
  3. Clinical pharmacist reviews medication and provides education
  4. Medication ships via overnight delivery with temperature control

For refills:

  • Accredo provides automatic refill reminders
  • Track shipments through myCigna portal or Accredo website
  • 24/7 pharmacist support available
Tip: Set up your Accredo account immediately after PA approval to avoid delays in first shipment.

Annual Planning and Renewals

Plan ahead for potential changes that could affect your Isturisa coverage.

What Changes Annually

Formulary updates:

  • Drug tier placement may change January 1st
  • New prior authorization requirements possible
  • Step therapy protocols can be added or modified

Benefit design changes:

  • Deductibles and out-of-pocket maximums reset
  • Coinsurance percentages may adjust
  • Specialty pharmacy networks can change

Renewal Action Steps

October-December each year:

  1. Review next year's formulary for any Isturisa changes
  2. Confirm Accredo remains in-network
  3. Check if prior authorization criteria have changed
  4. Renew manufacturer copay card if eligible
  5. Reapply to foundation programs (grants typically expire annually)

Conversation Scripts

Use these templates when calling Cigna, Accredo, or your doctor's office.

Calling Cigna Member Services

"Hi, I need information about coverage for Isturisa, spelled I-S-T-U-R-I-S-A, generic name osilodrostat. My member ID is [number]. Can you tell me: Is this covered on my formulary? What tier is it on? Do I need prior authorization? What's my specialty drug coinsurance? Must I use Accredo pharmacy?"

Requesting Peer-to-Peer Review

"I'm calling to request a peer-to-peer review for my patient's Isturisa prior authorization denial. The patient has confirmed Cushing's disease with elevated cortisol levels and is not a surgical candidate. I have additional clinical documentation to support medical necessity. When can we schedule the physician-to-physician call?"

Following Up on Prior Authorization

"I'm checking on the status of a prior authorization for Isturisa submitted [date] for patient [name], member ID [number]. The 72-hour timeline has passed, and we need to know the decision to avoid treatment delays."

Counterforce Health specializes in helping patients and clinicians navigate complex prior authorization and appeals processes for specialty medications like Isturisa. Their platform analyzes denial letters and creates targeted, evidence-backed appeals that align with each payer's specific requirements, significantly improving approval rates for rare disease treatments.

FAQ

How long does Cigna prior authorization take for Isturisa in Ohio? Standard requests receive decisions within 72 hours; urgent requests within 24 hours. If Cigna doesn't respond within these timeframes, they must provide coverage until resolved.

What if Isturisa is non-formulary on my Cigna plan? You can request a formulary exception with clinical justification showing medical necessity and why formulary alternatives are inappropriate. Your doctor must document contraindications or failures with preferred drugs.

Can I get an expedited appeal if my Isturisa is denied? Yes, if delaying treatment could seriously jeopardize your health. Mark all appeal documents as "EXPEDITED" and provide medical documentation of urgency. Ohio allows 72-hour expedited external reviews.

Does Ohio step therapy apply if I failed medications in another state? Yes, if you have documentation of previous medication trials and failures. Your medical records from other states can satisfy Ohio step therapy requirements – ensure your Ohio endocrinologist has complete treatment history.

How much will Isturisa cost with Cigna in Ohio? Costs vary by plan, but expect high specialty tier coinsurance (often 25-40% after deductible). With manufacturer copay assistance, commercial patients may pay only $20/month. Foundation grants can cover additional costs.

What happens if Accredo can't fill my Isturisa prescription? Contact Cigna immediately to request a network adequacy exception allowing retail pharmacy dispensing. Document all attempts to fill through Accredo and any delays in treatment.

Can I appeal to Ohio if I have an employer self-funded plan? Self-funded ERISA plans follow federal rules, not Ohio's external review process. However, many voluntarily provide similar appeal rights. Check your Summary Plan Description or contact HR for your plan's appeal procedures.

What clinical documentation strengthens my Isturisa appeal? Include: abnormal cortisol test results with dates and values, detailed surgical history or contraindications, previous medication trials with specific outcomes, current symptoms and functional impairment, and supporting literature on Isturisa's efficacy for your specific situation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and circumstances. Always verify current requirements with your insurance company and consult your healthcare provider for medical guidance. For additional help with insurance appeals and prior authorizations, Counterforce Health provides specialized support for complex medication access challenges.

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