By Counterforce Health Team in Isturisa (osilodrostat) —

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

Quick Answer: Getting Isturisa (Osilodrostat) Covered by Cigna in Virginia

Isturisa requires prior authorization from Cigna and must be prescribed by an endocrinologist for adults with Cushing's disease when surgery isn't an option or wasn't curative. You'll need to try step therapy alternatives first (ketoconazole, cabergoline, metyrapone) unless contraindicated. Submit PA requests through CoverMyMeds or Cigna's provider portal. If denied, you have 180 days for internal appeals, then 120 days for Virginia's external review through the State Corporation Commission. Start today by verifying your endocrinologist has documented your surgical history and prior medication failures.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather What You Need
  4. Submit the Prior Authorization Request
  5. Follow-Up and Timelines
  6. If You're Asked for More Information
  7. If Your Request Is Denied
  8. Virginia External Review Process
  9. Renewal and Re-authorization
  10. Quick Reference Checklist

What This Guide Covers

This guide helps Virginia patients and their healthcare teams navigate Cigna's prior authorization process for Isturisa (osilodrostat), an FDA-approved medication for adults with Cushing's disease. We'll walk you through the specific requirements, forms, timelines, and appeal rights that apply in Virginia.

Isturisa is a specialty medication that blocks cortisol production and requires careful monitoring by an endocrinologist. Because it costs several thousand dollars monthly, Cigna requires prior approval and has specific medical necessity criteria you must meet.

Before You Start: Verify Your Coverage

Check Your Plan Type

  • Commercial Cigna plans: Follow the standard PA process outlined below
  • Self-funded employer plans: May have different requirements; check with your HR department
  • Medicare Advantage through Cigna: Similar PA requirements but different appeal timelines

Confirm Specialty Pharmacy Routing

Isturisa is typically dispensed through Accredo, Cigna's specialty pharmacy partner. Your prescription will need to be sent there rather than a retail pharmacy. Call Accredo at 877-826-7657 to verify coverage and coordinate with your doctor's office.

Formulary Status

Isturisa is classified as a specialty medication on Cigna formularies with a quantity limit of 180 tablets per 30 days. It requires both prior authorization and step therapy completion.

Gather What You Need

Clinical Documentation Required

Diagnosis Requirements:

  • ICD-10 code E24.0 (Pituitary-dependent Cushing's disease)
  • At least two abnormal test results from:
    • 24-hour urinary free cortisol (UFC) above normal
    • Late-night salivary cortisol above reference range
    • Low-dose dexamethasone suppression test showing inadequate suppression

Surgical History:

  • Documentation that pituitary surgery is not an option OR
  • Records showing surgery was performed but not curative
  • If surgery wasn't attempted, medical contraindications must be documented

Step Therapy Documentation: You must have tried and failed, been intolerant to, or had contraindications to these medications (unless clinically inappropriate):

  • Ketoconazole
  • Cabergoline (Dostinex)
  • Metyrapone (Metopirone)
  • Mitotane (Lysodren)

Prescriber Requirements:

  • Must be prescribed by or in consultation with an endocrinologist or Cushing's syndrome specialist
  • Prescriber must document ongoing monitoring plan
Clinician Corner: When writing the medical necessity letter, include specific cortisol levels, dates of prior therapies, reasons for discontinuation, and current symptoms affecting quality of life. Reference the Endocrine Society's 2015 Clinical Practice Guidelines for Cushing's disease to support your rationale.

Submit the Prior Authorization Request

  1. CoverMyMeds: Most efficient option with real-time status updates
  2. ExpressPAth: Cigna's provider portal for PA requests
  3. MyAccredoPatients: Direct coordination with specialty pharmacy
  4. EHR Integration: If your practice has integrated ePA

Manual Submission

  • Phone: 1-800-882-4462
  • Fax: 1-866-873-8279

What to Include in Your Request

  • Completed PA form with all required fields
  • Clinical notes supporting diagnosis and prior treatments
  • Laboratory results (UFC, salivary cortisol, DST)
  • Documentation of step therapy completion or contraindications
  • Prescriber attestation of ongoing monitoring

Follow-Up and Timelines

Standard Review Timeline

  • Non-urgent requests: 72 hours for determination
  • Urgent requests: 24 hours for determination
  • Both prescriber and patient receive notification

When to Follow Up

Call Cigna at 1-800-882-4462 if you haven't received a decision within:

  • 3 business days for standard requests
  • 1 business day for urgent requests

Sample Follow-Up Script: "I'm calling to check the status of a prior authorization request for Isturisa submitted on [date] for patient [name], member ID [number]. Can you provide the current status and any additional information needed?"

Document all reference numbers and representative names for your records.

If You're Asked for More Information

Cigna may request additional clinical documentation to support medical necessity. Common requests include:

  • More detailed surgical history or contraindication documentation
  • Additional laboratory values or imaging studies
  • Clarification on why specific step therapy medications failed
  • Updated clinical notes showing current symptom severity

Respond promptly to these requests, as delays can result in automatic denials.

If Your Request Is Denied

Common Denial Reasons and Solutions

Denial Reason How to Address
Incomplete step therapy Provide documentation of trials/failures for required medications
Non-specialist prescriber Have an endocrinologist co-sign or take over prescribing
Insufficient surgical documentation Obtain operative notes or contraindication letter from surgeon
Missing diagnostic criteria Submit complete lab results showing hypercortisolism

Internal Appeal Process

You have 180 days from the denial date to file an internal appeal with Cigna:

  1. First-level appeal: Submit additional documentation supporting medical necessity
  2. Second-level appeal: If first appeal denied, request peer-to-peer review with endocrinologist
  3. Expedited appeals: Available for urgent medical situations (72-hour decision)

Submit appeals through the same channels used for PA requests or call 1-800-882-4462.

Virginia External Review Process

If Cigna denies your internal appeals, Virginia law provides an independent external review option through the State Corporation Commission (SCC).

Eligibility Requirements

  • Must complete Cigna's internal appeal process first
  • Denial must be based on medical necessity, appropriateness, or experimental/investigational designation
  • Must file within 120 days of final internal denial

How to File External Review

  1. Complete Form 216-A (download here)
  2. Attach denial letter from Cigna's final internal appeal decision
  3. Submit to SCC via:
    • Mail: Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218
    • Fax: (804) 371-9915
    • Email: [email protected]

External Review Timeline

  • Standard review: 45 days for decision
  • Expedited review: 72 hours for urgent cases (requires physician certification)
  • Final decision: Binding on both you and Cigna

For assistance with external review, contact the SCC Consumer Services at 1-877-310-6560.

From Our Advocates: We've seen several Virginia patients successfully overturn Cigna denials through external review by ensuring their endocrinologist provided detailed documentation of why surgery wasn't viable and how previous medications failed due to side effects rather than just "lack of efficacy." The independent medical reviewers appreciate specificity about dosages tried and duration of trials.

Renewal and Re-authorization

Isturisa approvals are typically granted for one year. Start the renewal process 60-90 days before expiration to avoid treatment gaps.

Renewal Documentation

  • Updated clinical notes showing continued benefit
  • Recent cortisol levels demonstrating treatment response
  • Documentation of ongoing specialist monitoring
  • Evidence of medication adherence

Calendar reminder: Set alerts 90 days before your approval expires to begin renewal paperwork.

Quick Reference Checklist

Before Submitting PA:

  • Endocrinologist confirmed as prescriber
  • ICD-10 code E24.0 documented
  • Two abnormal cortisol tests on file
  • Step therapy medications tried/contraindicated
  • Surgical history documented
  • Accredo contacted for specialty pharmacy coordination

After Submission:

  • Reference number documented
  • Follow-up call scheduled if no response in 72 hours
  • Appeal timeline noted (180 days from denial)
  • Virginia external review option confirmed (120 days from final denial)

Getting specialized help: Counterforce Health helps patients and clinicians navigate complex prior authorization processes by analyzing denial letters and crafting evidence-based appeals. Their platform can identify specific gaps in PA submissions and generate targeted responses aligned with payer requirements.

Frequently Asked Questions

How long does Cigna's PA process take in Virginia? Standard requests receive decisions within 72 hours, urgent requests within 24 hours. Virginia doesn't impose additional state-specific timelines beyond federal requirements.

What if Isturisa isn't on my Cigna formulary? You can request a formulary exception by demonstrating medical necessity and providing clinical documentation. The process is similar to standard PA but may require additional justification.

Can I request an expedited appeal if denied? Yes, if your doctor certifies that waiting could seriously jeopardize your health. Expedited appeals receive decisions within 72 hours.

Does Virginia's external review cost anything? No, Virginia provides external review at no cost to consumers. The SCC covers all administrative expenses.

What happens if I move to another state during treatment? Your Cigna coverage should continue, but appeal rights would transfer to your new state's regulations. Contact Cigna to confirm coverage continuity.

For additional support with your Cigna prior authorization or appeal, Counterforce Health offers specialized assistance in turning insurance denials into successful approvals through evidence-based advocacy and payer-specific strategies.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage determinations. Prior authorization requirements and appeal processes may change; verify current procedures with your insurer and state regulators.

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