By Counterforce Health Team in Isturisa (osilodrostat) —

How to Get Isturisa (Osilodrostat) Covered by UnitedHealthcare in Washington: Requirements Checklist and Appeals Guide

Answer Box: Getting Isturisa Covered by UnitedHealthcare in Washington

UnitedHealthcare requires prior authorization for Isturisa (osilodrostat) for adult Cushing's disease patients who aren't surgical candidates or had unsuccessful surgery. The fastest path to approval: 1) Confirm your diagnosis with elevated urinary free cortisol and endocrinologist consultation, 2) Submit UnitedHealthcare's prior authorization form with surgical history documentation, and 3) Use Optum Specialty Pharmacy for dispensing. If denied, Washington residents have strong appeal rights through internal review and Independent Review Organizations (IROs). Start today by calling UnitedHealthcare Member Services to verify your plan's specialty pharmacy requirements and download the current PA form.

Table of Contents

Who Should Use This Guide

This requirements checklist is designed for patients with Cushing's disease and their healthcare teams navigating UnitedHealthcare coverage for Isturisa (osilodrostat). You'll benefit most if you're dealing with:

  • Initial prior authorization requests for Isturisa
  • Denied coverage that needs appealing
  • Confusion about specialty pharmacy requirements
  • Questions about Washington state appeal rights

Expected outcome: Following this guide systematically increases your chances of approval and helps you navigate denials more effectively. Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned with each payer's specific requirements.

Member & Plan Basics

Coverage Verification Steps

Before starting your prior authorization request:

  1. Confirm active UnitedHealthcare coverage through your member portal or by calling the number on your insurance card
  2. Identify your plan type (commercial, Medicare Advantage, or employer-sponsored)
  3. Check your pharmacy benefit structure - Isturisa is typically covered under pharmacy benefits
  4. Verify deductible status and specialty tier copayment amounts
Note: Self-funded employer plans may have different requirements than standard UnitedHealthcare policies.

Plan-Specific Considerations

UnitedHealthcare's specialty pharmacy requirements vary by plan design. Some key differences include:

  • Standard Commercial Plans: Require Optum Specialty Pharmacy for most specialty medications
  • Medicare Advantage: May have additional step therapy requirements
  • Employer Plans: Could have customized formulary restrictions

Clinical Criteria Requirements

FDA-Approved Indication

Isturisa is approved for adult patients with Cushing's disease who are not candidates for pituitary surgery or for whom surgery has not been curative. UnitedHealthcare's prior authorization criteria align with this FDA indication.

Key Clinical Requirements

Requirement Documentation Needed Where to Find It
Age ≥18 years Date of birth Patient chart
Confirmed Cushing's disease diagnosis Lab results showing elevated cortisol UFC, salivary cortisol, or DST results
Surgical status documentation Operative notes or contraindication letter Neurosurgery records or endocrinologist note
Endocrinologist involvement Consultation note or prescription Specialist documentation

Diagnostic Testing Requirements

For insurance approval, you'll need evidence of hypercortisolism through:

  • 24-hour Urinary Free Cortisol (UFC): Values >300 μg/day strongly support diagnosis
  • Late-night salivary cortisol: Elevated levels indicate loss of circadian rhythm
  • Dexamethasone suppression test: Failure to suppress cortisol appropriately
Tip: Multiple abnormal tests strengthen your case. Single borderline results may trigger denials.

Coding and Billing Information

Essential Medical Codes

  • Primary ICD-10 Code: E24.0 (Pituitary-dependent Cushing's disease)
  • NDC Numbers: Use the specific NDC for your prescribed strength
  • HCPCS J-Code: Not currently assigned; billing uses NDC for pharmacy claims

Billing Considerations

Isturisa is dispensed as an oral medication under pharmacy benefits, not as a medical benefit requiring J-codes. Always verify the exact NDC matches your prescription strength when submitting claims.

Documentation Packet Essentials

Provider Note Elements

Your endocrinologist's documentation should include:

  1. Clear diagnosis statement with ICD-10 code E24.0
  2. Symptom documentation (weight gain, hypertension, diabetes, etc.)
  3. Laboratory evidence of hypercortisolism with specific values and dates
  4. Surgical history - either contraindications or failed previous surgery
  5. Treatment rationale explaining why Isturisa is medically necessary
  6. Monitoring plan for potential side effects

Letter of Medical Necessity Components

A strong letter should address:

  • Patient-specific factors making surgery inappropriate
  • Failed alternative treatments if any were tried
  • Clinical guidelines supporting Isturisa use
  • Expected outcomes and monitoring plan
  • Dosing rationale based on patient weight and response

Required Attachments

  • Recent laboratory results (UFC, salivary cortisol)
  • Imaging studies (pituitary MRI if available)
  • Prior authorization form (completed in full)
  • Prescription with exact dosing instructions
  • Insurance card copy

Submission Process

Correct Form and Submission Method

UnitedHealthcare requires their specific prior authorization notification form for Isturisa requests. Submit through:

  1. UnitedHealthcare Provider Portal (fastest processing)
  2. Fax submission (verify current fax number with UHC)
  3. Mail submission for plans requiring hard copies

Common Form Completion Errors

Avoid these frequent rejection triggers:

  • Incomplete diagnosis codes - always include E24.0
  • Missing surgical history section - document why surgery isn't appropriate
  • Unclear dosing information - specify mg strength and frequency
  • Unsigned forms - ensure prescriber signature and date
  • Missing NPI numbers - include prescriber and facility identifiers

Specialty Pharmacy Requirements

Optum Specialty Pharmacy Network

UnitedHealthcare typically requires Isturisa dispensing through Optum Specialty Pharmacy or approved network partners. Benefits include:

  • Clinical pharmacist support for side effect monitoring
  • Refill coordination and adherence programs
  • Insurance processing assistance and prior authorization support
  • Home delivery with temperature-controlled shipping

Prescription Transfer Process

To transfer your prescription to Optum Specialty:

  1. Call 1-855-427-4682 to initiate transfer
  2. Provide prescription details and insurance information
  3. Confirm delivery address and preferred contact method
  4. Schedule initial consultation with specialty pharmacist
Important: Don't fill your first prescription elsewhere if your plan requires specialty pharmacy dispensing, as this could trigger coverage issues.

After Submission: What to Expect

Timeline and Status Tracking

  • Initial review: 3-5 business days for standard requests
  • Clinical review: Additional 5-10 days if medical director review needed
  • Approval notification: Via phone, fax, or provider portal
  • Denial letters: Include specific reasons and appeal instructions

What to Record

Keep detailed records including:

  • Confirmation numbers from all submissions
  • Representative names from phone conversations
  • Submission dates and methods used
  • Follow-up dates for status checks
  • All correspondence received from UnitedHealthcare

Common Denial Prevention Tips

Five Critical Pitfalls to Avoid

  1. Incomplete surgical documentation - Always explain why surgery isn't appropriate or wasn't curative
  2. Missing endocrinologist involvement - Primary care prescriptions often get denied
  3. Insufficient lab evidence - Include multiple cortisol measurements over time
  4. Wrong specialty pharmacy - Verify network requirements before dispensing
  5. Incomplete prior authorization forms - Double-check every required field

Strengthening Your Request

  • Include recent photos showing Cushingoid features if applicable
  • Document functional impairment from untreated Cushing's disease
  • Reference FDA prescribing information to support medical necessity
  • Provide treatment timeline showing urgency of intervention

Washington State Appeals Process

Washington residents have robust appeal rights when UnitedHealthcare denies coverage. The state's appeals framework provides multiple levels of review.

Internal Appeals Process

Timeline: File within 180 days of denial date

Standard Appeals: 14 calendar days for UnitedHealthcare response Expedited Appeals: 3 calendar days when health is at serious risk

External Review Through IRO

If internal appeals fail, Washington's Independent Review Organization process provides:

  • Expert medical review by specialists familiar with Cushing's disease
  • Binding decisions that UnitedHealthcare must follow
  • 30-day standard timeline (72 hours for urgent cases)
  • No cost to patients for the review process

Getting Help

Washington's Insurance Consumer Hotline (1-800-562-6900) provides free assistance with appeals. Counterforce Health also specializes in turning insurance denials into successful appeals by crafting evidence-backed rebuttals tailored to each payer's specific requirements.

Quick Reference Checklist

Before You Start

  • Verify active UnitedHealthcare coverage
  • Confirm Cushing's disease diagnosis with lab evidence
  • Obtain endocrinologist consultation
  • Document surgical contraindications or failure
  • Identify required specialty pharmacy

Documentation Packet

  • Completed UnitedHealthcare PA form
  • Provider letter with ICD-10 code E24.0
  • Laboratory results (UFC, salivary cortisol)
  • Surgical history documentation
  • Prescription with exact dosing
  • Insurance card copy

After Submission

  • Record confirmation numbers
  • Schedule status check calls
  • Monitor for approval/denial letters
  • Prepare appeal documents if needed
  • Contact specialty pharmacy for dispensing

FAQ

How long does UnitedHealthcare prior authorization take for Isturisa? Standard requests typically take 5-10 business days. Expedited reviews for urgent cases can be completed in 72 hours.

What if Isturisa is non-formulary on my plan? Non-formulary medications can still be covered through medical necessity appeals. Document why formulary alternatives aren't appropriate for your specific case.

Can I request an expedited appeal in Washington? Yes, if your health could be in serious jeopardy without treatment. Both UnitedHealthcare and Washington's IRO process offer expedited timelines.

Does step therapy apply if I've tried other treatments outside Washington? Previous treatment failures should be documented regardless of where they occurred. Include medical records showing inadequate response or intolerance.

What happens if my employer plan is self-funded? Self-funded plans may not follow standard UnitedHealthcare policies. Check your Summary Plan Description or contact HR for specific requirements.

How much does Isturisa cost with UnitedHealthcare coverage? Costs depend on your plan's specialty tier structure and deductible status. Specialty medications typically have higher copayments, often $100-500+ monthly.

Can I appeal directly to Washington state regulators? You must exhaust internal appeals first, then use Washington's IRO process. The Insurance Commissioner can assist with procedural questions but doesn't override coverage decisions.

What if my prescription was denied at the pharmacy? Contact UnitedHealthcare immediately to verify prior authorization status. If approved, the issue may be with specialty pharmacy routing or NDC coding.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and state regulations can change. Always verify current requirements with UnitedHealthcare and consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals, consider consulting with healthcare advocates or legal professionals specializing in insurance coverage disputes.

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