By Counterforce Health Team in Isturisa (osilodrostat) —

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

Answer Box: Getting Isturisa Covered by Humana in Michigan

Eligibility: Isturisa (osilodrostat) requires prior authorization from Humana for adult Cushing's disease when surgery isn't an option or wasn't curative. Fastest path: Have your endocrinologist submit PA with documented hypercortisolism (2+ abnormal tests: UFC, late-night salivary cortisol, or dexamethasone suppression), surgical history/contraindications, and failed alternatives. First step today: Call Humana at 1-800-555-2546 to verify formulary status and get PA forms, then gather your cortisol lab results and surgical records. Appeals follow federal Medicare timelines (not Michigan DIFS) with 65 days to file.

Table of Contents

  1. Humana Plan Types and Isturisa Coverage
  2. Formulary Status and Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Network
  5. Cost-Share Considerations
  6. Submission Process and Forms
  7. Medical Necessity Documentation
  8. Appeals Process in Michigan
  9. Common Denial Reasons and Solutions
  10. Patient Assistance Programs
  11. FAQ

Humana Plan Types and Isturisa Coverage

Humana's coverage for Isturisa (osilodrostat) varies significantly by plan type in Michigan. Most Michigan Humana members have Medicare Advantage plans, which follow federal formulary rules rather than state regulations.

Medicare Advantage Plans: These plans typically require prior authorization for specialty medications like Isturisa. Coverage decisions follow CMS guidelines, and appeals use the federal 5-level process rather than Michigan's DIFS external review system.

Medicaid Plans: Humana's Michigan Medicaid plans may cover Isturisa at no cost for eligible members, but prior authorization is still required to demonstrate medical necessity.

Commercial Plans: Less common in Michigan, these follow Humana's commercial formulary with varying copay structures and PA requirements.

Note: Michigan's Department of Insurance and Financial Services (DIFS) handles external reviews only for non-Medicare plans. Medicare appeals go through federal channels.

Formulary Status and Tier Placement

Isturisa's formulary placement determines your out-of-pocket costs and coverage requirements. As a specialty medication for rare disease, it typically appears on higher tiers requiring substantial cost-sharing.

Coverage at a Glance

Requirement Details Where to Verify Source
Prior Authorization Required for all plan types Humana Drug List Search Humana formulary
Formulary Tier Specialty tier (varies by plan) Member portal or drug list Plan documents
Step Therapy May require failed alternatives PA form or provider portal Coverage policy
Quantity Limits Based on FDA dosing Pharmacy or plan Clinical guidelines
Prescriber Restrictions Endocrinologist preferred PA requirements (verify with source linked above)

To check your specific plan's coverage, use Humana's online Drug List Search tool or call Customer Care at the number on your ID card.

Prior Authorization Requirements

Humana requires prior authorization for Isturisa across all plan types. The PA process evaluates medical necessity based on FDA-approved indications and clinical guidelines.

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Patient/Clinic): Call Humana Clinical Pharmacy Review at 1-800-555-2546 to confirm PA requirements for your specific plan.
  2. Gather Documentation (Clinic): Collect cortisol lab results, surgical records, prior therapy attempts, and current clinical notes showing Cushing's disease diagnosis.
  3. Submit PA Request (Prescriber): Complete Humana's PA form via provider portal or fax with all supporting documentation (timeline: 5-7 business days for standard review).
  4. Follow Up (Clinic): Track submission status through Humana's provider portal and respond promptly to any requests for additional information.
  5. Prepare for Potential Appeal (Patient/Clinic): If denied, you have 65 days to file a redetermination with additional clinical evidence.
  6. Coordinate Specialty Pharmacy (Patient): Once approved, work with CenterWell Specialty Pharmacy at 844-486-2668 for fulfillment.
  7. Schedule Monitoring (Prescriber): Set up regular follow-ups for cortisol monitoring and PA renewal (typically annual).

Specialty Pharmacy Network

Humana routes Isturisa through its specialty pharmacy network, primarily CenterWell Specialty Pharmacy, which handles complex medications requiring special storage, handling, or patient support.

Key requirements for Michigan providers:

  • Prescriptions must be filled at Humana network pharmacies
  • CenterWell Specialty Pharmacy is the preferred option for home delivery
  • Call 844-486-2668 (TTY: 711) for prescription coordination
  • Access provider resources at provider.humana.com/pharmacy-resources

CenterWell provides clinical support, financial assistance coordination, and adherence monitoring—valuable services for patients starting this complex therapy.

Cost-Share Considerations

Isturisa's high cost means understanding your plan's cost-sharing structure is crucial for budgeting and accessing patient assistance programs.

Typical cost-sharing patterns:

  • Deductible: May apply before coverage begins
  • Copay/Coinsurance: Usually percentage-based for specialty tiers
  • Out-of-pocket maximum: Annual cap on your costs
Educational note: This information is for planning purposes only. Actual costs depend on your specific plan design and should be verified with Humana directly.

Submission Process and Forms

Clinician Corner: Medical Necessity Documentation

When submitting Isturisa PA requests, include these essential elements:

Required clinical documentation:

  • Confirmed Cushing's disease diagnosis with supporting labs
  • Documentation of surgical contraindication or failed surgery
  • Prior therapy attempts and outcomes
  • Current clinical status and treatment goals
  • Proposed monitoring plan

Laboratory requirements (based on Endocrine Society guidelines):

  • At least 2 abnormal first-line tests: 24-hour UFC, late-night salivary cortisol, or 1-mg overnight dexamethasone suppression test
  • ACTH levels to confirm pituitary source
  • Baseline electrolytes and liver function

Submit via Humana's provider portal or contact provider services for current submission methods.

Appeals Process in Michigan

If Humana denies your Isturisa request, Michigan residents with Medicare plans follow federal appeals timelines, not state processes.

Appeals Timeline for Humana Medicare Plans

Level 1 - Plan Redetermination:

  • Filing deadline: 65 days from denial notice
  • Decision timeline: 7 days (standard) or 72 hours (expedited)
  • How to file: Member portal, mail, phone, or through prescriber

Level 2 - Independent Review Entity:

  • Filing deadline: 60 days from Level 1 denial
  • Decision timeline: 7 days (standard) or 72 hours (expedited)
  • Reviewer: Independent organization like MAXIMUS

Expedited appeals are available when standard timelines could jeopardize your health. Your prescriber must provide written support for expedited review.

Important: Michigan's DIFS external review process does NOT apply to Medicare plans. Use only the federal appeals process for Humana Medicare coverage.

For detailed appeals guidance, visit Medicare's appeals information or call Humana member services.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
Insufficient diagnosis documentation Submit complete lab workup 2+ abnormal cortisol tests, ACTH levels
Missing surgical history Provide operative reports or contraindication letter Surgical records or specialist letter
Prescriber not specialist Have endocrinologist co-sign or transfer prescription Endocrinologist involvement documentation
Step therapy not met Document failed/contraindicated alternatives Prior therapy records, intolerance notes
Incomplete prior authorization Resubmit with all required fields Complete PA form with clinical notes

Patient Assistance Programs

Recordati Rare Diseases, Isturisa's manufacturer, offers patient support programs that may help with costs and access:

  • Recordati Patient Support Program: Potential copay assistance and prior authorization support
  • Foundation grants: Various rare disease foundations offer medication assistance
  • State programs: Michigan residents may qualify for additional state-sponsored assistance

Contact Recordati directly or ask your specialty pharmacy about available programs when coordinating your prescription.

When to Escalate

If you've exhausted Humana's appeals process without success, consider these options:

For Medicare plans: Contact Medicare at 1-800-MEDICARE (1-800-633-4227) for guidance on external review options.

For non-Medicare plans: File an external review with Michigan DIFS at 877-999-6442 within 127 days of final denial.

For all plans: Document your experience and consider filing a complaint with appropriate regulators if you believe proper procedures weren't followed.

FAQ

How long does Humana prior authorization take for Isturisa in Michigan? Standard PA decisions take 5-7 business days. Expedited reviews (when health is at risk) are completed within 72 hours.

What if Isturisa is non-formulary on my Humana plan? You can request a formulary exception through Humana's appeals process. Your doctor must demonstrate medical necessity and that formulary alternatives are inappropriate.

Can I request an expedited appeal for Isturisa? Yes, if delaying treatment would jeopardize your health. Your prescriber must provide written documentation supporting the urgent need.

Does step therapy apply if I've failed treatments outside Michigan? Yes, documented treatment failures from any location should satisfy step therapy requirements. Ensure your new Michigan provider has complete records.

What happens if I move between Humana plans in Michigan? You may need to restart the PA process if formulary requirements differ between plans. Contact Humana before switching to understand coverage changes.

Who can file appeals on my behalf? Your prescriber, a family member, or another authorized representative can file appeals with your written consent.

How often do I need to renew Isturisa prior authorization? Typically annually, but renewal frequency varies by plan. Your prescriber will receive renewal notices before expiration.

What if my Cushing's disease was diagnosed outside Michigan? Out-of-state diagnoses are accepted if properly documented. Ensure your Michigan providers have complete records from your previous care team.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to create point-by-point rebuttals that align with each payer's specific requirements, pulling the right clinical evidence and meeting procedural deadlines to improve approval rates for complex medications like Isturisa.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by individual plan and circumstances. Always consult with your healthcare provider about treatment decisions and verify coverage details directly with Humana. For personalized assistance with complex coverage issues, consider working with experienced advocates like those at Counterforce Health.

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