By Counterforce Health Team in Isturisa (osilodrostat) —

The Requirements Checklist to Get Isturisa (osilodrostat) Covered by Aetna (CVS Health) in New Jersey

Answer Box: To get Isturisa (osilodrostat) covered by Aetna (CVS Health) in New Jersey, you need prior authorization with documented Cushing's disease diagnosis, failed or contraindicated pituitary surgery, and endocrinologist prescription. Submit via Aetna's specialty pharmacy PA form with clinical notes and lab results. If denied, appeal within 180 days; New Jersey offers external review through IHCAP. Start by calling Aetna member services to confirm your plan's specialty drug coverage and obtain the current PA form.

Table of Contents

Who Should Use This Checklist

This checklist is designed for patients with Cushing's disease and their healthcare teams seeking Aetna (CVS Health) coverage for Isturisa (osilodrostat) in New Jersey. Use this if:

  • You have confirmed Cushing's disease (pituitary-dependent hypercortisolemia)
  • Pituitary surgery has failed or is contraindicated
  • Your endocrinologist has prescribed Isturisa
  • You have Aetna commercial insurance or Medicare Advantage through CVS Health

Expected Outcome: Following this checklist improves your chances of first-submission approval and helps you navigate the appeals process if needed. Most specialty drug prior authorizations are decided within 30-45 days, with expedited reviews available for urgent cases.

Member & Plan Basics

Coverage Verification

Before starting the prior authorization process:

Requirement Action Needed Where to Find
Active Aetna Coverage Verify current enrollment and benefits Aetna member portal or call member services
Specialty Drug Benefits Confirm specialty tier coverage Review your Summary of Benefits or call Aetna
Deductible Status Check if deductible applies to specialty drugs Member portal under "Claims & Coverage"
CVS Specialty Pharmacy Verify if required for dispensing Aetna formulary or specialty pharmacy list
Note: Aetna typically requires specialty medications like Isturisa to be dispensed through CVS Specialty Pharmacy or approved network partners.

Clinical Criteria

Aetna's medical policy for Isturisa requires meeting specific clinical criteria:

Primary Requirements

  1. Confirmed Diagnosis: Cushing's disease (pituitary-dependent) with supporting lab evidence
  2. Age Requirement: Patient must be 18 years or older
  3. Surgical History: Documentation that pituitary surgery has failed or is contraindicated
  4. Specialist Prescription: Must be prescribed by or in consultation with an endocrinologist

Step Therapy Documentation

Aetna requires evidence that surgical intervention was attempted and failed, or clear documentation of surgical contraindication:

  • Post-surgical failure: Biochemical evidence of persistent hypercortisolism after pituitary surgery
  • Surgical contraindication: Medical reasons why surgery is not feasible (high operative risk, anatomical factors, patient refusal with medical justification)

Laboratory Thresholds

Include recent results showing persistent hypercortisolism:

  • 24-hour urinary free cortisol (UFC) above normal range
  • Late-night salivary cortisol elevation
  • Dexamethasone suppression test results

Coding Requirements

ICD-10 Diagnosis Codes

  • Primary: E24.0 (Pituitary-dependent Cushing's disease)
  • Secondary codes as appropriate for complications (hypertension, diabetes, osteoporosis)

HCPCS/Billing Information

  • HCPCS Code: J3490 (Unclassified drugs) - include drug name and NDC in claim details
  • NDC Numbers: Varies by strength (1mg, 5mg, 10mg tablets)
  • Quantity Limits: Typically 120 tablets per 30 days
Important: There is no specific J-code for osilodrostat as of 2024-2025. Always use J3490 with complete drug identification.

Documentation Packet

Provider Note Elements

Your endocrinologist's clinical notes should include:

Diagnosis Documentation:

  • Clinical presentation and symptoms
  • Biochemical confirmation of Cushing's disease
  • Imaging results (pituitary MRI)
  • Differential diagnosis workup

Treatment History:

  • Detailed surgical history and outcomes
  • Previous medical therapies tried and outcomes
  • Contraindications to alternative treatments
  • Current symptom severity and impact

Letter of Medical Necessity Components

A comprehensive Letter of Medical Necessity should address:

  1. Patient identification and insurance details
  2. Clinical diagnosis with supporting evidence
  3. FDA indication alignment - reference that Isturisa is approved for adults with Cushing's disease when surgery is not curative or not an option
  4. Failed surgical intervention or contraindication documentation
  5. Medical necessity - explain why Isturisa is required for this patient
  6. Monitoring plan - outline safety and efficacy monitoring per FDA guidelines

Required Attachments

  • Recent laboratory results (UFC, cortisol levels)
  • Surgical reports or contraindication documentation
  • Relevant imaging studies
  • Previous treatment records
  • Current medication list

Submission Process

Form Requirements

  • Aetna Prior Authorization Form: Use the current specialty medication PA form
  • Complete all fields: Incomplete forms are the most common cause of delays
  • Legible submission: Ensure all handwritten information is clearly readable

Submission Methods

Method Timeline Best For
Aetna Provider Portal Real-time submission tracking Standard requests
Fax Submission 24-48 hours processing When portal is unavailable
Electronic PA System Fastest processing Integrated EMR systems
Tip: Always request a confirmation number and save submission receipts.

Common Form Errors to Avoid

  1. Missing patient insurance ID or group number
  2. Incomplete prescriber NPI or contact information
  3. Missing ICD-10 diagnosis codes
  4. Unclear dosing or quantity requested
  5. No specialist consultation documentation

Specialty Pharmacy Routing

CVS Specialty Pharmacy Process

  1. Prescription Transfer: Your prescriber sends the prescription to CVS Specialty
  2. Insurance Verification: CVS Specialty verifies coverage and PA status
  3. Patient Contact: Specialty pharmacy contacts you to coordinate delivery
  4. Shipment Tracking: Monitor delivery through CVS Specialty portal

Preferred Network Verification

Confirm that your chosen specialty pharmacy is in Aetna's network:

  • CVS Specialty Pharmacy (primary)
  • Other approved specialty pharmacies (verify current list)

When it comes to navigating complex prior authorization requirements for specialty medications like Isturisa, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and drafts point-by-point rebuttals aligned to each payer's specific rules and requirements.

After Submission

Status Monitoring

  • Check status within 2-3 business days of submission
  • Standard timeline: 30-45 days for non-urgent requests
  • Expedited timeline: 72 hours for urgent medical situations
  • Document everything: Keep records of all communications

What to Record

  • Submission confirmation number
  • Date and method of submission
  • Representative names and reference numbers
  • Status check dates and outcomes
  • Any additional information requests

Common Denial Prevention Tips

Five Critical Pitfalls and Solutions

  1. Incomplete Surgical History
    • Problem: Vague documentation of surgical failure
    • Solution: Include specific dates, procedures, and biochemical outcomes
  2. Missing Specialist Consultation
    • Problem: Primary care provider prescription without endocrinology involvement
    • Solution: Ensure endocrinologist is prescriber or provides consultation note
  3. Inadequate Lab Documentation
    • Problem: Outdated or insufficient cortisol measurements
    • Solution: Submit recent UFC and cortisol levels showing persistent hypercortisolism
  4. Wrong Diagnosis Code
    • Problem: Using unspecified Cushing's syndrome code (E24.9)
    • Solution: Use specific E24.0 code for pituitary-dependent disease
  5. Form Submission Errors
    • Problem: Incomplete or illegible prior authorization forms
    • Solution: Double-check all required fields and use electronic submission when possible

Appeals Process in New Jersey

Internal Appeals with Aetna

If your initial request is denied:

Level 1 Appeal:

  • Timeline: File within 180 days of denial
  • Decision: 30 days for standard, 72 hours for expedited
  • Requirements: Submit additional clinical documentation addressing denial reasons

Level 2 Appeal:

  • Timeline: File within 60 days of Level 1 denial
  • Decision: 30 days for standard review
  • Process: Independent medical review by Aetna

New Jersey External Review (IHCAP)

After exhausting internal appeals, New Jersey residents can access external review:

Filing Requirements:

  • Timeline: 60 days from final internal appeal decision
  • Fee: $25 (or $2 with financial hardship documentation)
  • Process: Independent medical experts review your case

Contact Information:

For additional support navigating the appeals process, Counterforce Health provides specialized assistance in preparing evidence-backed appeals that address payer-specific denial reasons and procedural requirements.

From our advocates: We've seen cases where patients initially denied for Isturisa received approval on appeal by providing comprehensive surgical failure documentation and detailed endocrinologist notes explaining why alternative treatments weren't suitable. The key was addressing each specific denial reason with targeted clinical evidence rather than submitting generic appeal letters.

Printable Checklist

Pre-Submission Checklist ✓

  • Active Aetna coverage verified
  • Specialty drug benefits confirmed
  • Endocrinologist consultation documented
  • Cushing's disease diagnosis confirmed (ICD-10: E24.0)
  • Surgical history/contraindication documented
  • Recent lab results obtained (UFC, cortisol)
  • Current Aetna PA form obtained
  • Letter of medical necessity prepared
  • All attachments gathered

Submission Checklist ✓

  • PA form completely filled out
  • All required fields completed legibly
  • Correct ICD-10 and HCPCS codes used
  • Prescriber information and NPI included
  • Patient insurance details verified
  • Submission method selected (portal/fax)
  • Confirmation number obtained
  • Submission receipt saved

Post-Submission Checklist ✓

  • Status check scheduled (2-3 days post-submission)
  • CVS Specialty Pharmacy contacted
  • Patient contact information updated
  • Appeal timeline noted (180 days from denial)
  • External review information saved
  • Communication log maintained

Frequently Asked Questions

Q: How long does Aetna prior authorization take for Isturisa in New Jersey? A: Standard requests typically take 30-45 days. Expedited requests for urgent medical situations are decided within 72 hours.

Q: What if Isturisa is not on Aetna's formulary? A: You can request a formulary exception with supporting clinical documentation. The same PA process applies with additional justification for non-formulary status.

Q: Can I request an expedited appeal if denied? A: Yes, if delaying treatment would seriously jeopardize your health. Your doctor must provide documentation supporting the urgent medical need.

Q: Does step therapy apply if I've tried other treatments outside New Jersey? A: Yes, document all prior treatments regardless of where they were tried. Include medical records from previous providers showing treatment failures or intolerances.

Q: What happens if my appeal is denied at the external review level? A: External review decisions in New Jersey are binding on the insurance company. If approved, Aetna must provide coverage. If denied, you may have limited additional options depending on your specific situation.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for personalized guidance. Coverage policies may change, and individual circumstances vary.

For official New Jersey insurance regulations and consumer assistance, contact the New Jersey Department of Banking and Insurance at 1-800-446-7467.

Sources & Further Reading

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