By Counterforce Health Team in Isturisa (osilodrostat) —

How to Get Isturisa (Osilodrostat) Covered by Cigna in Pennsylvania: Appeals Process & Decision Tree

Answer Box: Getting Isturisa Covered by Cigna in Pennsylvania

You'll likely qualify if you have documented Cushing's disease with abnormal cortisol tests (UFC, salivary cortisol, or DST) and either can't have pituitary surgery or surgery failed. First step today: Have your endocrinologist call Cigna at 1-800-882-4462 to request prior authorization criteria for osilodrostat. If denied, Pennsylvania's external review program overturns about 50% of denials. Submit appeals within 180 days for internal review, then within 4 months for state external review through the Pennsylvania Insurance Department.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If You're Likely Eligible: Document Checklist
  4. If You're Possibly Eligible: Tests to Request
  5. If You're Not Yet Eligible: Alternative Options
  6. If You're Denied: Pennsylvania Appeals Process
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & How to Fix Them
  9. FAQ: Cigna and Isturisa in Pennsylvania

How to Use This Decision Tree

This guide walks you through Cigna's approval process for Isturisa (osilodrostat) in Pennsylvania step by step. Start with the eligibility triage below to understand where you stand, then follow the specific pathway for your situation.

Important: Isturisa is a specialty medication for Cushing's disease that typically requires prior authorization through Cigna's pharmacy benefit manager, Express Scripts. Most requests go through EviCore by Evernorth or can be submitted via CoverMyMeds.

Eligibility Triage: Do You Qualify?

Work through these questions with your endocrinologist to determine your approval likelihood:

✅ Likely Eligible if ALL of these apply:

  • Confirmed Cushing's disease diagnosis (pituitary source)
  • At least two abnormal cortisol tests on separate occasions:
    • 24-hour urine free cortisol (UFC) >77 mcg/24 hr, ideally >4x upper limit
    • Late-night salivary cortisol >2.0 ng/mL (5.5 nmol/L)
    • Low-dose dexamethasone suppression test showing failure to suppress
  • Either pituitary surgery is contraindicated OR you've had surgery that failed/recurred
  • Prescribed by an endocrinologist

⚠️ Possibly Eligible if some of these apply:

  • Cushing's syndrome suspected but testing incomplete
  • Only one abnormal cortisol test documented
  • Surgery candidacy unclear or not yet evaluated
  • Prescribed by non-endocrinology specialist

❌ Not Yet Eligible if:

  • No documented hypercortisolism
  • Cushing's syndrome from non-pituitary source
  • Surgery is recommended and feasible but hasn't been attempted
  • No specialist evaluation

If You're Likely Eligible: Document Checklist

Your endocrinologist should gather these documents before submitting the prior authorization:

Required Clinical Documentation:

  • Diagnosis confirmation: Pituitary MRI or imaging showing adenoma (if available)
  • Biochemical proof: At least two abnormal cortisol tests from separate collections
  • Surgical history: Either contraindication letter from neurosurgeon OR documentation of failed/recurrent disease post-surgery
  • Current symptoms: Clinical notes describing active Cushing's signs/symptoms
  • ICD-10 codes: E24.0 (Pituitary-dependent Cushing's disease)

Submission Process:

  1. Electronic submission preferred: Use CoverMyMeds or submit through your EHR system via Surescripts
  2. Alternative: Fax completed prior authorization form to 1-866-873-8279
  3. Phone option: Call Cigna at 1-800-882-4462 for urgent cases
Tip: Request expedited review if delaying treatment could worsen symptoms or cause complications. Cigna processes expedited requests within 24 hours.

If You're Possibly Eligible: Tests to Request

Ask your endocrinologist to order these tests to strengthen your case:

Essential Testing (if not done):

  • 24-hour urine free cortisol: Collect on 2-3 separate occasions
  • Late-night salivary cortisol: Two samples taken between 11 PM-midnight
  • 1 mg overnight dexamethasone suppression test: Take dexamethasone at 11 PM, check cortisol at 8 AM

Additional Supportive Tests:

  • Midnight serum cortisol (if inpatient)
  • ACTH level to confirm pituitary source
  • High-dose dexamethasone suppression test (8 mg) if needed to differentiate from ectopic ACTH

Timeline to Reapply:

  • Allow 2-4 weeks between cortisol tests for reliability
  • Resubmit prior authorization once you have two abnormal results
  • Consider Counterforce Health's platform to help organize evidence and draft targeted appeals based on Cigna's specific criteria

If You're Not Yet Eligible: Alternative Options

Discuss These Options with Your Doctor:

  • Pituitary surgery consultation: If you haven't seen a neurosurgeon, this may be required first
  • Alternative medications:
    • Pasireotide LAR (Signifor LAR) - may have different coverage criteria
    • Mifepristone for glucose control in Cushing's syndrome
    • Off-label options like ketoconazole or metyrapone

Exception Request Strategy:

Even if you don't meet standard criteria, your doctor can request a formulary exception through Cigna's process. Include:

  • Clinical rationale for why standard alternatives won't work
  • Literature supporting osilodrostat for your specific situation
  • Documentation of contraindications to preferred therapies

If You're Denied: Pennsylvania Appeals Process

Pennsylvania residents have strong appeal rights with a new state-supervised external review program that overturns about 50% of denials.

Step 1: Internal Appeals with Cigna

  • Timeline: Must appeal within 180 days of denial
  • First-level review: Submit appeal through Cigna member portal or call 1-800-882-4462
  • Peer-to-peer option: Request that your doctor speak directly with Cigna's medical director
  • Decision timeline: 72 hours for standard, 24 hours for expedited

Step 2: Pennsylvania External Review (if internal appeal fails)

  • Who's eligible: Commercial insurance members (not self-funded employer plans)
  • Timeline: Must request within 4 months of final adverse determination
  • How to apply: Submit online at pa.gov external review portal
  • Decision timeline: 45 days for standard, 72 hours for expedited
  • Success rate: 50% of appeals are overturned in patient's favor

Step 3: Get Free Help

Contact the Pennsylvania Health Law Project at 1-800-274-3258 for free legal assistance with appeals, especially for rare disease medications.

Coverage Requirements at a Glance

Requirement What Cigna Typically Needs Where to Find It Source
Prior Authorization Yes, through Express Scripts/EviCore Cigna PA forms Cigna
Prescriber Endocrinologist preferred Medical license verification Verify with plan
Diagnosis Confirmed Cushing's disease ICD-10: E24.0 Clinical notes
Lab Tests 2+ abnormal cortisol tests UFC >77 mcg/24hr, salivary >2.0 ng/mL Lab reports
Surgery Status Contraindicated or failed Neurosurgery consultation note Medical records
Appeal Deadline 180 days (internal) Denial letter date Cigna appeals
External Review 4 months (after internal) Final adverse determination PA Insurance Dept

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"Diagnosis not adequately documented" Submit at least two abnormal cortisol tests from separate occasions with endocrinologist interpretation
"Surgery should be tried first" Obtain neurosurgery consultation documenting contraindications or provide records of failed prior surgery
"Prescribed by non-specialist" Transfer prescription to endocrinologist or have endocrinologist co-sign with rationale
"Not medically necessary" Submit clinical notes showing active Cushing's symptoms, complications, and treatment goals
"Alternative therapies not tried" Document previous trials of other medications or contraindications to alternatives

Clinician Corner: Medical Necessity Letter Checklist

When writing the medical necessity letter for Isturisa, include:

Essential Elements:

  • Patient presentation: Specific Cushing's disease symptoms and complications
  • Diagnostic workup: Detailed results of cortisol testing with dates and values
  • Surgical status: Clear statement about surgery candidacy with specialist consultation
  • Treatment rationale: Why osilodrostat is appropriate for this patient's specific situation
  • Monitoring plan: How you'll assess response and manage potential side effects

Helpful Guidelines to Reference:

  • FDA prescribing information for approved indications
  • Endocrine Society guidelines on Cushing's syndrome management
  • Pituitary Society recommendations for medical management
From our advocates: We've seen approvals improve significantly when clinicians include specific cortisol values, dates of testing, and a clear timeline showing the progression from diagnosis through treatment attempts. One effective approach is creating a chronological summary that demonstrates the medical necessity step by step.

FAQ: Cigna and Isturisa in Pennsylvania

Q: How long does Cigna's prior authorization take in Pennsylvania? A: Standard reviews take up to 72 hours once complete documentation is submitted. Expedited reviews are completed within 24 hours if clinical urgency is documented.

Q: What if Isturisa isn't on Cigna's formulary? A: Your doctor can request a formulary exception with clinical rationale explaining why covered alternatives aren't appropriate.

Q: Can I get an expedited appeal in Pennsylvania? A: Yes, both Cigna's internal process and Pennsylvania's external review offer expedited timelines (24-72 hours) when delays could jeopardize your health.

Q: Does step therapy apply to Isturisa? A: This varies by plan. Your doctor can request a step therapy override if you've tried required medications or if they're contraindicated.

Q: What's the cost of Isturisa without insurance? A: The wholesale acquisition cost varies by dose strength but is typically in the high four- to five-figure range monthly. Check with Recordati's patient support program for assistance options.

Q: Can pharmacy benefits managers override my doctor's prescription? A: PBMs like Express Scripts can require prior authorization, but they cannot change your doctor's prescribed therapy without approval. Appeals processes exist specifically to challenge these requirements.

When navigating complex insurance requirements for rare disease medications like Isturisa, having the right support makes all the difference. Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, identifying specific policy requirements, and crafting evidence-backed rebuttals that speak directly to each payer's criteria. Their platform helps patients, clinicians, and pharmacies streamline the prior authorization process and improve approval rates for specialty medications.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual policy terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for guidance specific to your situation. For personalized help with appeals in Pennsylvania, contact the Pennsylvania Health Law Project at 1-800-274-3258.

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