By Counterforce Health Team in Isturisa (osilodrostat) —

How to Get Isturisa (Osilodrostat) Covered by Humana in Florida: Complete Appeals Guide with Forms and Timelines

Answer Box: Getting Isturisa (Osilodrostat) Covered by Humana in Florida

Fastest path to approval: Isturisa (osilodrostat) is covered by Humana as a Tier 5 specialty drug with prior authorization required. You need endocrinologist documentation of Cushing disease diagnosis (two abnormal tests: UFC, salivary cortisol, or DST), prior treatment failures, and medical necessity. If denied, you have 65 days to appeal with supporting clinical evidence. Start by gathering your denial letter, complete diagnostic workup, and prescriber's medical necessity letter—then submit through Humana's member portal or mail to their Grievance Department.

First step today: Contact your endocrinologist to ensure all diagnostic documentation is complete and request a detailed medical necessity letter citing FDA labeling and treatment guidelines.

Table of Contents

Understanding the Denial: Decode Your Letter

When Humana denies Isturisa (osilodrostat), your Notice of Denial of Medical Coverage contains critical information you'll need for appeals. Look for:

  • Denial reason code (often "not medically necessary" or "experimental/investigational")
  • Appeal deadline (65 calendar days from the denial date)
  • Required documentation for reconsideration
  • Benefit type (medical vs. pharmacy—Isturisa typically falls under specialty pharmacy)

The denial letter must explain Humana's specific coverage criteria and which requirements weren't met. Common issues include incomplete Cushing disease documentation or missing endocrinologist evaluation.

Fixable Causes: Common Documentation Gaps

Many Isturisa denials stem from correctable documentation issues:

Missing Diagnostic Evidence

  • Incomplete cortisol testing (need at least two abnormal results from UFC, salivary cortisol, or dexamethasone suppression test)
  • Lack of endocrinologist interpretation of results
  • Missing ICD-10 codes for Cushing disease (E24.0 for pituitary-dependent)

Insufficient Treatment History

  • No documentation of surgical evaluation or contraindication
  • Missing prior therapy trials (ketoconazole, pasireotide, etc.)
  • Inadequate explanation of treatment failures or intolerances

Prescriber Requirements

  • Non-endocrinologist prescriber (many policies require specialist management)
  • Missing medical necessity letter with clinical rationale

Coverage Requirements at a Glance

Requirement Details Documentation Needed Source
Prior Authorization Required for all Tier 5 specialty drugs PA form + clinical records Humana Formulary
Diagnosis Confirmed Cushing disease Two abnormal cortisol tests + endocrinologist evaluation FDA Prescribing Information
Prescriber Endocrinologist preferred Medical license verification Plan-specific policy
Prior Treatments Document surgical evaluation/contraindication Medical records, operative notes Clinical coverage policy
Appeal Deadline 65 calendar days from denial Written appeal + supporting docs Humana Appeals Process

Step-by-Step: Fastest Path to Approval

1. Gather Complete Diagnostic Documentation

Who: Patient + endocrinologist
What: Collect all cortisol test results (UFC, salivary cortisol, DST), imaging studies, and specialist consultation notes
Timeline: 1-2 weeks
Submit via: Include with initial PA request

2. Obtain Medical Necessity Letter

Who: Prescribing endocrinologist
What: Detailed letter explaining diagnosis, prior treatments, contraindications to surgery, and why Isturisa is medically necessary
Timeline: 3-5 business days
Submit via: Humana provider portal or fax

3. Submit Prior Authorization

Who: Healthcare provider or patient
What: Complete PA form with all supporting documentation
Timeline: 7-14 days for standard review
Submit via: Electronic submission preferred through provider portal

4. Request Peer-to-Peer if Denied

Who: Prescribing physician
What: Direct conversation with Humana medical director
Timeline: Must request within 5 days of denial notification
Process: Call provider services to schedule

5. File Formal Appeal if Necessary

Who: Patient or authorized representative
What: Written appeal with comprehensive clinical evidence
Timeline: Within 65 days of denial
Submit via: Appeals address or online portal

First-Level Appeal Process

If your initial prior authorization is denied, you have 65 calendar days to file an appeal with Humana. The appeal must include:

Required Components:

  • Copy of the denial letter
  • Completed appeal form (available from Humana member services)
  • Updated medical necessity letter from your endocrinologist
  • Complete diagnostic workup showing Cushing disease
  • Documentation of prior treatment attempts or contraindications

Submission Options:

  • Online: Through Humana member portal (fastest processing)
  • Mail: Humana Grievance and Appeal Department, P.O. Box 14165, Lexington, KY 40512-4165
  • Phone: Call member services number on your ID card

Timeline: Humana must respond within 30 days for pre-service appeals or 60 days for post-service appeals.

Peer-to-Peer Review Strategy

A peer-to-peer review allows your physician to speak directly with Humana's medical director before a final denial. This conversation can be crucial for complex cases like Cushing disease.

Physician Preparation Checklist:

  • Recent endocrinology consultation notes (within 12 months)
  • Complete cortisol testing results with interpretation
  • Documentation of surgical evaluation or contraindication
  • Prior medication trials and outcomes
  • Current symptom severity and functional impairment
  • Specific references to FDA labeling and treatment guidelines

Key Talking Points:

  • Confirmed Cushing disease diagnosis per Endocrine Society guidelines
  • Why surgical options are not feasible or have failed
  • How Isturisa specifically addresses the patient's clinical needs
  • Potential consequences of treatment delay

External Review in Florida

If Humana's internal appeal fails, Florida residents can request an independent external review through the Florida Department of Financial Services.

Process Overview:

  • Eligibility: Must exhaust Humana's internal appeals first
  • Deadline: Within 120 days (4 months) of final internal denial
  • Cost: Free to patients
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Outcome: Binding decision—if overturned, Humana must cover the medication

How to Request:

  1. Contact Florida DFS at 1-877-693-5236
  2. Complete external review request form
  3. Submit final denial letter and all medical documentation
  4. Include physician statement of medical necessity

Required Documentation:

  • All correspondence with Humana
  • Complete medical records supporting diagnosis
  • Prescriber's detailed rationale for Isturisa
  • Evidence of treatment urgency (if requesting expedited review)

Medical Necessity Letter Checklist

Your endocrinologist's medical necessity letter is crucial for approval. It should include:

Patient-Specific Clinical Information:

  • Confirmed Cushing disease diagnosis with specific test results
  • Current symptoms and functional impairment
  • Prior treatment history (medications, surgery evaluation)
  • Contraindications to alternative therapies
  • Expected treatment outcomes with Isturisa

Evidence-Based Support:

  • References to FDA prescribing information
  • Citations from Endocrine Society guidelines
  • Peer-reviewed literature supporting use
  • Specific dosing and monitoring plan

Clinical Rationale:

  • Why Isturisa is the most appropriate treatment option
  • How it addresses the patient's specific clinical needs
  • Potential consequences of denial or delay
From Our Advocates: We've found that appeals with comprehensive endocrinologist letters citing specific FDA indications and patient-specific contraindications to alternatives have significantly higher approval rates. The key is connecting your unique clinical picture to the established evidence base.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Provide detailed clinical rationale Medical necessity letter + diagnostic evidence
"Experimental/investigational" Cite FDA approval and guidelines FDA label + Endocrine Society guidelines
"Step therapy required" Document prior treatment failures Medication history + intolerance documentation
"Non-formulary drug" Request formulary exception Comparative effectiveness evidence
"Prescriber not qualified" Use endocrinologist Specialist consultation + ongoing care plan

Appeals Timeline & Deadlines

Humana Internal Appeals (Florida):

  • File within: 65 calendar days of denial
  • Decision timeline: 30 days (pre-service) or 60 days (post-service)
  • Expedited option: 72 hours if urgent medical need

Florida External Review:

  • File within: 120 days of final internal denial
  • Decision timeline: 45 days standard, 72 hours expedited
  • No cost to patient

Part D Prescription Appeals:

  • File within: 65 calendar days
  • Decision timeline: 7 days standard, 72 hours expedited

Cost Savings & Patient Assistance

While working through the appeals process, explore cost assistance options:

Manufacturer Support:

  • Recordati Rare Diseases may offer patient assistance programs
  • Check for copay cards or foundation grants
  • Contact manufacturer directly for eligibility requirements

State Programs:

  • Florida's pharmaceutical assistance programs (verify current eligibility)
  • Medicaid coverage if income-qualified

Healthcare System Resources:

  • Hospital charity care programs
  • Specialty pharmacy financial counseling
  • Clinical trial opportunities

When to Escalate: Florida Regulators

If you encounter procedural violations or unreasonable delays, contact Florida regulators:

Florida Department of Financial Services

  • Phone: 1-877-693-5236
  • Online: Submit insurance concern through DFS website
  • Role: Investigates insurance company compliance, facilitates external reviews

When to File Complaints:

  • Humana fails to respond within required timelines
  • Denial reasons are unclear or contradict policy
  • Appeal process violations
  • Discriminatory coverage decisions

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific rules and procedural requirements.

FAQ: Humana & Isturisa Coverage

Q: How long does Humana prior authorization take for Isturisa in Florida? A: Standard reviews take 7-14 days; expedited reviews for urgent cases are completed within 72 hours. Electronic submissions through the provider portal are typically faster than fax or mail.

Q: What if Isturisa is not on Humana's formulary? A: You can request a formulary exception by demonstrating medical necessity and showing that formulary alternatives are inappropriate or ineffective for your condition.

Q: Can I request an expedited appeal if my condition is worsening? A: Yes, if waiting for standard review could seriously jeopardize your health, you or your provider can request expedited processing with decisions within 72 hours.

Q: Does step therapy apply if I've tried treatments outside Florida? A: Yes, treatment history from other states counts toward step therapy requirements. Ensure your physician documents all prior therapies with dates and outcomes.

Q: What happens if both internal and external appeals fail? A: Explore manufacturer assistance programs, clinical trials, or consider working with Counterforce Health to identify additional appeal strategies or alternative coverage pathways.

Q: Who can file an appeal on my behalf? A: You, your healthcare provider, or an authorized representative can file appeals. Family members need completed authorization forms to act on your behalf.

Sources & Further Reading

Disclaimer: This guide is for informational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms, medical circumstances, and current policies. Always consult with your healthcare provider and insurance company for personalized guidance. For official appeals assistance, contact the Florida Department of Financial Services at 1-877-693-5236.

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