By Counterforce Health Team in Isturisa (osilodrostat) —

How to Get Isturisa (Osilodrostat) Covered by UnitedHealthcare in Florida: Complete Guide with Forms and Appeal Scripts

Answer Box: Getting Isturisa Covered by UnitedHealthcare in Florida

UnitedHealthcare requires prior authorization for Isturisa (osilodrostat) in Florida for both Medicaid and Medicare Advantage plans. The fastest path to approval requires: (1) confirmed Cushing's disease diagnosis with two positive biochemical tests, (2) documentation that pituitary surgery isn't an option or wasn't curative, and (3) prescription by an endocrinologist. Submit through the UnitedHealthcare Provider Portal or call 888-397-8129 (Medicaid) or 866-273-9444 (Medicare). If denied, you have 30 days to appeal, with external review available through Florida's Department of Financial Services after exhausting internal appeals.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required Must get approval before filling prescription UHC Provider Portal UHC PA Requirements
Diagnosis Documentation Two positive tests: UFC, salivary cortisol, or dexamethasone suppression Medical records Endocrine Guidelines
Prescriber Requirement Endocrinologist or specialist consultation Provider credentials Coverage Guidelines
Surgery Documentation Proof surgery isn't option or wasn't curative Operative notes/imaging UHC PA Notification
Appeal Deadline 30 days from denial notification Denial letter OptumRx Appeals

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis Documentation

Who does it: Your endocrinologist
What's needed: Results from at least two of these tests:

  • 24-hour urinary free cortisol (UFC) - abnormal if >300 µg/24 hours
  • Late-night salivary cortisol - elevated levels
  • 1-mg dexamethasone suppression test - lack of suppression (cortisol >5 µg/dL)

Timeline: Tests may take 1-2 weeks to complete
Source: Cushing's Diagnostic Guidelines

2. Document Surgery Status

Who does it: Your endocrinologist
What's needed: Clear documentation that pituitary surgery is either:

  • Not an option due to medical contraindications
  • Not curative (with operative notes showing persistent disease)
  • High surgical risk due to patient factors

Timeline: Immediate if records exist
Source: UHC Isturisa PA Requirements

3. Submit Prior Authorization

Who does it: Your doctor's office
How to submit:

Timeline: Decision within 15 business days
Source: UHC Prior Auth Process

4. Track Your Request

Who does it: You or your doctor's office
How: Log into member portal or call member services
Timeline: Check after 5-7 business days

5. If Approved: Fill Prescription

Who does it: You
Where: Specialty pharmacy (typically OptumRx)
Cost help: Apply for R.A.R.E. Patient Support Program for $20 copay

6. If Denied: File Appeal (See Appeals Section Below)

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Documents Needed
"Diagnosis not confirmed" Submit additional lab results Two positive biochemical tests from different methods
"Surgery not attempted" Provide surgical contraindication letter Specialist evaluation showing high risk or contraindications
"Not prescribed by specialist" Get endocrinology consultation Referral to endocrinologist or specialist co-signature
"Medical necessity not established" Submit comprehensive clinical summary Treatment history, symptom documentation, quality of life impact
"Alternative treatments not tried" Document prior therapy failures Medication history showing intolerance or ineffectiveness

Appeals Playbook for UnitedHealthcare in Florida

Internal Appeals (Level 1)

Deadline: 30 days from denial notification
How to file:

  • Online: UnitedHealthcare member portal
  • Mail: Address on denial letter
  • Fax: OptumRx appeals fax (verify current number)

Timeline: 30 calendar days for decision
Required documents:

  • Original denial letter
  • Updated medical necessity letter
  • Additional clinical documentation
  • Any new test results

Source: OptumRx Appeals Process

Expedited Appeals

When to use: Urgent medical need where delay could harm health
Timeline: 72 hours for decision
How to request: Call member services and state "expedited appeal needed"

External Review (After Internal Appeals)

When available: After exhausting internal appeals
Deadline: 4 months after final internal denial
How to file: Through Florida Department of Financial Services
Cost: Free to consumer
Timeline: 30-45 days for decision

Medical Necessity Letter Template

Clinician Corner: Your endocrinologist's letter should include these key elements:

Patient Information:

  • Name, DOB, insurance ID
  • Diagnosis: Cushing's disease (ICD-10: E24.0)

Clinical Justification: "The patient has confirmed Cushing's disease based on [list specific tests and results]. Pituitary surgery is not an option due to [specific contraindication/failed surgery with dates]. Isturisa (osilodrostat) is medically necessary as the patient has [describe symptoms and impact on quality of life]."

Supporting Evidence:

  • Attach lab results (UFC, cortisol levels)
  • Include imaging reports if available
  • Document any previous treatment failures
  • Reference FDA labeling for approved indication

Monitoring Plan: "Patient will be monitored for efficacy with repeat UFC levels and for safety including QTc monitoring, liver function tests, and electrolyte levels per FDA labeling."

Source: FDA Isturisa Labeling

Cost-Saving Options

R.A.R.E. Patient Support Program

  • $20 copay for commercially insured patients (including UnitedHealthcare)
  • Bridge therapy for coverage gaps
  • Insurance navigation support
  • How to enroll: Doctor completes form at RareResources.com, fax to Anovo Specialty Rx (1-855-813-2039)
  • Contact: 1-888-855-7273

Eligibility: Commercial insurance required (Medicaid/Medicare not eligible for copay program)
Source: Isturisa Patient Support

Alternative Financial Assistance

  • Patient advocate organizations for Cushing's disease
  • State pharmaceutical assistance programs
  • Hospital charity care programs

When to Escalate

File State Insurance Complaint

When: UnitedHealthcare doesn't follow proper appeal procedures or timelines
Where: Florida Department of Financial Services
Phone: 1-877-MY-FL-CFO (1-877-693-5236)
What to include:

  • Insurance policy information
  • Denial letters and appeal correspondence
  • Medical records supporting necessity
  • Timeline of events

Contact Your State Representatives

For systemic issues with prior authorization or appeals processes, contact:

  • Florida Office of Insurance Regulation
  • Your state senator or representative
  • Florida Attorney General's office

FAQ

How long does UnitedHealthcare prior authorization take in Florida?
Standard prior authorization decisions are made within 15 business days. Expedited reviews for urgent cases are completed within 72 hours.

What if Isturisa is non-formulary on my UnitedHealthcare plan?
Non-formulary drugs can still be covered through the medical exception process. Your doctor needs to demonstrate medical necessity and that formulary alternatives aren't appropriate.

Can I request an expedited appeal if my condition worsens?
Yes. Call UnitedHealthcare member services immediately and explain the urgent medical need. Expedited appeals are decided within 72 hours.

Does step therapy apply if I've tried other treatments outside Florida?
Yes, prior treatment history from other states counts. Ensure your doctor documents all previous therapies, including dates, doses, and reasons for discontinuation.

What happens if UnitedHealthcare doesn't respond within the required timeframe?
If UnitedHealthcare misses deadlines, you can file a complaint with Florida's Department of Financial Services and may be able to proceed directly to external review.

How much does Isturisa cost without insurance?
Isturisa is a specialty medication with high costs, typically in the four- to five-figure range monthly depending on dose. The R.A.R.E. Patient Support Program provides assistance for uninsured patients who qualify.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that address the specific reasons for denial. We pull the right medical evidence—from FDA labeling to peer-reviewed studies—and weave it into appeals that meet each payer's requirements and procedural standards.

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 questions. For personalized help with insurance appeals, consider working with Counterforce Health or other patient advocacy services.

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