By Counterforce Health Team in Isturisa (osilodrostat) —

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

Answer Box: Getting Isturisa Covered by Cigna in Texas

Cigna requires prior authorization for Isturisa (osilodrostat) with specific clinical documentation. The fastest path to approval requires: (1) endocrinologist prescription with confirmed Cushing's disease diagnosis, (2) documented surgical contraindication or failure, and (3) abnormal cortisol test results (UFC, salivary cortisol, or DST). Submit via CoverMyMeds for quickest processing (5 business days). If denied, you have 180 days to appeal internally, then 4 months for Texas external review. Start today: Contact your endocrinologist to initiate prior authorization through Cigna's provider portal.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Approval
  4. Coding Requirements
  5. Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Requirements
  8. After Submission: Tracking Your Request
  9. Appeals Process in Texas
  10. Common Denial Reasons & How to Fix Them
  11. Frequently Asked Questions
  12. Quick Reference Checklist

Who Should Use This Guide

This guide is for Texas patients with Cushing's disease who need Isturisa (osilodrostat) coverage through Cigna, as well as their healthcare providers and caregivers. You'll find this most helpful if:

  • Your endocrinologist has recommended Isturisa for confirmed Cushing's disease
  • You're not a candidate for pituitary surgery or surgery wasn't curative
  • You have Cigna coverage (commercial, Medicare Advantage, or Medicaid managed care)
  • You've received a denial and need to appeal

Expected outcome: With complete documentation, most prior authorization requests are approved within 5-7 business days. If initially denied, appeals have meaningful success rates when proper clinical evidence is provided.

Member & Plan Basics

Coverage Requirements

Requirement Details Source
Prior Authorization Required for all Isturisa prescriptions Cigna PA Policy IP0044
Formulary Status Specialty tier; non-formulary on some plans Express Scripts Formulary
Age Restriction 18+ years only Cigna Coverage Policy
Specialty Pharmacy Must use Accredo for most plans Cigna Specialty Pharmacy

Plan Types and Considerations

  • Commercial plans: Standard PA process applies
  • Medicare Advantage: May have additional step therapy requirements
  • Medicaid managed care: Follow state Medicaid guidelines alongside Cigna criteria
Note: Self-funded employer plans (ERISA) follow federal appeal rules, not Texas state processes.

Clinical Criteria for Approval

Primary Requirements

Cigna requires all of the following for Isturisa approval:

  1. Confirmed endogenous Cushing's syndrome diagnosis with supporting lab evidence
  2. Endocrinologist prescription or consultation
  3. Surgical contraindication or failure documentation
  4. Age 18 or older

Diagnostic Evidence Required

You need at least two abnormal results from these tests:

  • 24-hour urine free cortisol (UFC) - elevated above normal range
  • Late-night salivary cortisol - elevated above normal range
  • Dexamethasone suppression test (DST) - abnormal suppression

Surgical Documentation

Provide one of the following:

  • Medical contraindication to transsphenoidal surgery
  • Persistent/recurrent disease after pituitary surgery
  • Awaiting surgery with urgent need for cortisol control
  • Post-radiation therapy with inadequate response

Coding Requirements

ICD-10 Diagnosis Codes

Code Description When to Use
E24.0 Pituitary-dependent Cushing's disease Confirmed ACTH-secreting pituitary adenoma
E24.1 Ectopic ACTH syndrome ACTH from non-pituitary source
E24.9 Cushing's syndrome, unspecified Only if subtype cannot be determined

HCPCS Billing Code

  • J3490: Unclassified drug code for Isturisa
  • Required documentation: Include drug name "osilodrostat," NDC number, and diagnosis code on claim

Documentation Packet

Medical Necessity Letter Components

Your endocrinologist's letter should include:

  1. Patient demographics and insurance information
  2. Confirmed diagnosis with specific test results and dates
  3. Symptom description and functional impact
  4. Surgical evaluation - contraindication or failure details
  5. Prior treatments attempted and outcomes
  6. Clinical rationale for Isturisa therapy
  7. Treatment goals and monitoring plan

Required Attachments

  • Complete endocrinology consultation notes
  • Abnormal cortisol test results (UFC, salivary cortisol, DST)
  • Surgical evaluation or contraindication documentation
  • Prior medication trial records (if applicable)
  • Current medication list and allergies
  • Recent lab results (electrolytes, liver function)

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to create point-by-point rebuttals aligned with each payer's specific requirements.

Submission Process

Step-by-Step Submission

  1. Gather all documentation (see checklist above)
  2. Submit via CoverMyMeds for fastest processing (~35% faster than fax)
  3. Alternative: Call Cigna PA line at 1-800-882-4462
  4. Include complete packet - incomplete submissions cause delays
  5. Request confirmation number and save all submission records
  6. Track status via provider portal or CoverMyMeds dashboard

Timeline Expectations

  • Standard requests: 5 business days
  • Expedited requests: 72 hours (urgent medical need)
  • Incomplete submissions: Additional 5-7 days for reprocessing

Specialty Pharmacy Requirements

Accredo Enrollment Process

Once approved, Cigna typically requires Accredo specialty pharmacy:

  1. Automatic enrollment: Cigna forwards approved PA to Accredo
  2. Patient contact: Accredo calls within 24-48 hours
  3. Shipment coordination: Temperature-controlled delivery arranged
  4. Ongoing refills: Accredo manages refill reminders and renewals

Alternative Options

Some plans may allow other specialty pharmacies - verify with Cigna member services before filling elsewhere.

After Submission: Tracking Your Request

What to Monitor

  • Confirmation number from submission
  • Status updates via provider portal
  • Request for additional information (respond within 5 business days)
  • Final determination letter

If Additional Information is Requested

Respond quickly with:

  • Specific documentation requested
  • Updated clinical notes if needed
  • Clarification of surgical contraindication
  • Additional lab results or imaging

Appeals Process in Texas

Internal Appeal Timeline

Step Deadline Decision Time How to Submit
File internal appeal 180 days from denial 30 days (standard) / 72 hours (expedited) Cigna appeals portal
Second-level internal After first denial 30 days Same process

Texas External Review (IRO)

After final internal denial:

  • Request deadline: 4 months from final denial
  • IRO decision time: 20 days (standard) / 72 hours (expedited)
  • Cost: Cigna pays IRO fees
  • Binding decision: IRO approval requires Cigna compliance
  • Contact: Texas Department of Insurance at 1-800-252-3439
From our advocates: We've seen cases where the initial denial was overturned at the first internal appeal level simply by including a more detailed surgical contraindication letter from the neurosurgeon. Don't assume the first denial is final - additional clinical documentation often makes the difference.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Diagnosis not confirmed Submit additional lab results At least 2 abnormal cortisol tests with dates
Missing surgical evaluation Obtain neurosurgeon consultation Letter stating contraindication or surgical failure
Non-specialist prescriber Get endocrinologist involvement Consultation note or co-management agreement
Insufficient prior therapy Document treatment history Records of failed/contraindicated alternatives
Administrative error Resubmit with corrections Complete PA form with all fields

Appeal Enhancement Tips

When appealing, Counterforce Health recommends including:

  • Point-by-point rebuttal of denial reasons
  • Updated medical necessity letter
  • Additional peer-reviewed literature supporting off-label use (if applicable)
  • Patient impact statement describing functional limitations

Frequently Asked Questions

How long does Cigna prior authorization take for Isturisa in Texas? Standard requests: 5 business days. Expedited requests (urgent medical need): 72 hours. Submit via CoverMyMeds for fastest processing.

What if Isturisa is non-formulary on my plan? Request a formulary exception with clinical justification. Include medical necessity letter explaining why formulary alternatives are inappropriate.

Can I request an expedited appeal if denied? Yes, if delay would jeopardize your health. Mark all submissions "URGENT" and explain clinical urgency in cover letter.

Does step therapy apply to Isturisa? Cigna doesn't explicitly require step therapy, but may request documentation of prior treatment failures or contraindications to alternatives.

What if I have an ERISA self-funded plan? ERISA plans follow federal appeal rules, not Texas state processes. You'll have 180 days for internal appeals but no Texas IRO option.

Who can help if Cigna doesn't follow proper timelines? Contact the Texas Department of Insurance at 1-800-252-3439 or file a complaint online. The Office of Public Insurance Counsel (1-877-611-6742) also assists consumers.

Quick Reference Checklist

Before Submitting

  • Active Cigna coverage verified
  • Endocrinologist prescription obtained
  • Cushing's disease diagnosis confirmed with labs
  • Surgical contraindication/failure documented
  • Prior treatments documented (if any)
  • Complete medical necessity letter prepared

Required Documents

  • PA form completed entirely
  • Medical necessity letter from endocrinologist
  • Abnormal cortisol test results (2+ tests)
  • Surgical evaluation notes
  • Current medication list
  • Insurance card copy

After Submission

  • Confirmation number saved
  • Status tracking set up
  • Calendar reminders for follow-up
  • Appeal deadline noted (180 days)
  • Accredo contact information ready

If Denied

  • Internal appeal filed within 180 days
  • Additional documentation gathered
  • External review requested within 4 months (if needed)
  • Texas Department of Insurance contacted (if needed)

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not be considered medical or legal advice. Coverage decisions depend on individual plan benefits and medical circumstances. Always consult your healthcare provider for medical decisions and contact Cigna directly for plan-specific information. For additional help with appeals in Texas, contact the Texas Department of Insurance at 1-800-252-3439.

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