CurrentAnthemPolicy INBCBS-CD-098069-25-SRS97052

Request for Prior Authorization - Cushing Syndrome Agents

A prior authorization request form and checklist for multiple Cushing syndrome pharmacologic agents (osilodrostat, mifepristone, mitotane, metyrapone, levoketoconazole, pasireotide formulations) used by Anthem for specified Indiana Medicaid lines of business. It lists per-drug PA clinical and age/diagnosis/contraindication/dose fields that must be completed by the prescriber and faxed to PA.

Policy Summary

PayerAnthem

PolicyRequest for Prior Authorization - Cushing Syndrome Agents

Policy CodePolicy INBCBS-CD-098069-25-SRS97052

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionPrescribing provider must complete all sections of the PA form, sign required attestations, include documentation (e.g., pregnancy test date when applicable), and fax to the Prior Authorization of Benefits Center at 844-864-7860 (retail) or 888-209-7838 (medical injectable).

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

7Agents listed requiring PA

Adult onlyAge restriction

Dose limitsOperational constraints

Policy summary and purpose

This is a prescriber-completed prior authorization (PA) form titled Request for Prior Authorization - Cushing Syndrome Agents used by Anthem Blue Cross and Blue Shield for specified Indiana Medicaid lines of business (Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, and Indiana PathWays for Aging). Providers contracted to serve these lines must follow group/ACO/PMG/IPA guidelines and complete all sections of the form; completed requests are to be faxed to the Prior Authorization of Benefits Center at 844-864-7860 (retail) or 888-209-7838 (medical injectable).

Policy number: INBCBS-CD-098069-25-SRS97052. Status: CURRENT. Subject: Prior Authorization Form for Cushing Syndrome Agents. Scope summary: A prior authorization request form and checklist for multiple Cushing syndrome pharmacologic agents (osilodrostat, mifepristone, mitotane, metyrapone, levoketoconazole, pasireotide formulations) used by Anthem for specified Indiana Medicaid lines of business; lists per-drug PA clinical and age/diagnosis/contraindication/dose fields that must be completed by the prescriber and faxed to PA.

The form operationalizes PA requirements per agent including adult age restrictions (member must be ≥ 18 years where specified), specific diagnoses (e.g., endogenous hypercortisolemia/Cushing's syndrome, inoperable adrenocortical cancer, pituitary-dependent hypercortisolism, diagnostic testing indications), drug-specific maximum dose limits, required prescriber attestations for listed contraindications, and documentation of a negative pregnancy test within the past 30 days when required. Examples of per-drug dose thresholds include: Isturisa ≤ 60 mg/day; Korlym ≤ 1200 mg/day; Lysodren ≤ 12 g/day; Metopirone ≤ 6 g/day; Recorlev ≤ 1.2 g/day; Signifor ≤ 2.4 mg/day; Signifor LAR 40 mg q4wks (Cushing's) or 60 mg q4wks (acromegaly).

Prescriber responsibilities include completing all form sections, signing required attestations (including absence of specified contraindications for agents such as mifepristone, mitotane, levoketoconazole, metyrapone), including date and documentation of negative pregnancy test when applicable, and faxing the completed PA form to the Prior Authorization of Benefits Center. The form also provides instructions for handling retroactive PA requests (dates of service prior to eligibility determination submitted separately when more than 30 calendar days prior).

Policy NumberINBCBS-CD-098069-25-SRS97052

PayerAnthem

Policy TitlePrior Authorization Form for Cushing Syndrome Agents

StatusCURRENT

Last review date2025-11-01

Next review date

Effective date

Prior authorization criteria by agent

PA requirements for Isturisa (osilodrostat phosphate)

Covered when ALL of the following are met:

ALL of the following

Member is ≥ 18 years of age
Yes/No checkbox
Diagnosis of endogenous hypercortisolemia in members with Cushing's syndrome for whom surgery is not an option or has not been curative
Yes/No checkbox
Dose requested is 60 mg/day or less≤ 60 mg/day
Yes/No checkbox

PA requirements for Korlym (mifepristone)

Covered when ALL of the following are met:

ALL of the following

Member is ≥ 18 years of age
Yes/No checkbox
Diagnosis of hyperglycemia secondary to hypercortisolism in members with endogenous Cushing's syndrome who have type 2 diabetes mellitus or glucose intolerance and have failed surgery or are not a candidate for surgery
Yes/No checkbox
Contraindication attestation: Prescriber attests that the member does not have any of the listed contraindications (concomitant use of listed medications including simvastatin, lovastatin, narrow therapeutic index CYP3A substrates e.g., cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, tacrolimus; systemic corticosteroids being utilized for life-saving purposes; endometrial carcinoma; endometrial hyperplasia with atypia; history of unexplained vaginal bleeding)
Attestation signature required
Pregnancy test: Member has had a negative pregnancy test in the past 30 days

PA requirements for Lysodren (mitotane)

Covered when ALL of the following are met:

ALL of the following

Diagnosis selection: Selected diagnosis is either Cushing's syndrome or inoperable adrenocortical cancer
Checkbox to select diagnosis
Member is ≥ 18 years of age
Yes/No checkbox
Pregnancy test: Member has had a negative pregnancy test in the past 30 daysNegative pregnancy test within past 30 days
Date and documentation required

PA requirements for Metopirone (metyrapone)

Covered when ALL of the following (relevant to indication) are met:

ALL of the following

Diagnosis selection: Selected diagnosis is one of: Cushing's syndrome; Pituitary-dependent hypercortisolism; Requiring diagnostic testing of HPA hormone function
Checkbox to select diagnosis
Age requirement: Member is ≥ 18 years of age (for all indications except diagnostic testing)
Yes/No checkbox; not required for diagnostic testing indication
Dose limit: Dose requested is 6 g/day or less≤ 6 g/day
Yes/No checkbox

PA requirements for Recorlev (levoketoconazole)

Covered when ALL of the following are met:

ALL of the following

Member is ≥ 18 years of age
Yes/No checkbox
Diagnosis of endogenous hypercortisolemia in members with Cushing's syndrome for whom surgery is not an option or has not been curative
Yes/No checkbox
Dose limit: Dose requested is 1.2 g/day or less≤ 1.2 g/day
Yes/No checkbox
Contraindication attestation: Prescriber attests that the member does not have any of the listed contraindications (prior drug-induced liver injury to ketoconazole/azole antifungals requiring discontinuation; acute or poorly controlled liver disease; baseline AST or ALT > 3x ULN; baseline QTcF > 470 msec; cirrhosis; concomitant QT-prolonging meds associated with ventricular arrhythmias; concomitant use with certain sensitive CYP3A4 or CYP3A4 and P-gP substrates; extensive metastatic liver disease; history of torsades de pointes/ventricular tachycardia/fibrillation/prolonged QT; recurrent symptomatic cholelithiasis)

PA requirements for Signifor (pasireotide diaspartate)

Covered when ALL of the following are met:

ALL of the following

Diagnosis of Cushing's syndrome in members for whom pituitary surgery is not an option or has not been curative
Yes/No checkbox
Member is ≥ 18 years of age
Yes/No checkbox
Dose limit: Dose requested is 2.4 mg/day or less≤ 2.4 mg/day
Yes/No checkbox

Contraindication attestation: Prescriber attests that the member does not have any of the listed contraindications (see form for detailed list)

PA requirements for Signifor LAR (pasireotide pamoate)

Covered when ALL of the following are met:

ALL of the following

Diagnosis selection: Selected diagnosis is either Cushing's syndrome (for whom pituitary surgery is not an option or has not been curative) or Acromegaly with inadequate response to surgery or surgery not an option
Checkbox to select diagnosis
Member is ≥ 18 years of age
Yes/No checkbox
Dose options
- 40 mg every 4 weeks for the diagnosis of Cushing's syndrome40 mg every 4 weeks
  Yes/No checkbox

Dose limits, attestations, and documentation requirements

Isturisa (osilodrostat) max dose≤ 60 mg/day

Korlym (mifepristone) max dose≤ 1200 mg/day

Lysodren (mitotane) max dose≤ 12 g/day

Metopirone (metyrapone) max dose≤ 6 g/day

Recorlev (levoketoconazole) max dose≤ 1.2 g/day

Signifor (pasireotide) max dose≤ 2.4 mg/day

Signifor LAR dose options40 mg q4wks (Cushing's) or 60 mg q4wks (acromegaly)

Pregnancy test requirementNegative pregnancy test within past 30 days (where specified)

Age restrictionAdult only

Prior Authorization

Submit completed PA form

Prescribing provider must complete all sections of the PA form, sign required attestations, include any required documentation (for example, date of negative pregnancy test when applicable), and fax the completed form to the Prior Authorization of Benefits Center at 844-864-7860 for retail or 888-209-7838 for medical injectable.

Documentation Required

Contraindication attestations and pregnancy test documentation

For agents with listed contraindications (mifepristone, mitotane, levoketoconazole, metyrapone), the prescriber must attest that the member does not have the specified contraindications and provide the date and documentation of a negative pregnancy test within the past 30 days where the form requests it.

Documentation Required

Dose limits enforced via PA form

Requested dose must fall within the per-drug maximums documented on the PA form. The form includes Yes/No confirmation checkboxes for dose limits for each agent (for example: Isturisa ≤ 60 mg/day; Korlym ≤ 1200 mg/day; Lysodren ≤ 12 g/day; Metopirone ≤ 6 g/day; Recorlev ≤ 1.2 g/day; Signifor ≤ 2.4 mg/day; Signifor LAR dose options 40 mg or 60 mg every 4 weeks). Prescribers must complete the Yes/No dose-limit confirmations on the form.

Submission rules and handling

Billing Rule

Retroactive PA handling

Submit PA requests for retroactive claims (dates of service prior to eligibility determination but within established eligibility timelines) separately from current PA requests. Specifically, use separate submissions when dates of service are prior to 30 calendar days of submission versus requests for dates of service 30 calendar days or less and going forward.

No CPT/HCPCS/ICD/NDC codes specified on formmixed

No codes listed

Definitions

PAPrior Authorization

Document versioning

2025-11-01reviewLatest

Last review

Policy Summary

PayerAnthem

PolicyRequest for Prior Authorization - Cushing Syndrome Agents

Policy CodePolicy INBCBS-CD-098069-25-SRS97052

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

Negative pregnancy test within past 30 days

Date and documentation required

Contraception counseling: Prescriber has counseled member on risks associated with conceiving while utilizing mifepristone and appropriate methods of non-hormonal contraception

Yes/No checkbox

Dose limit: Dose requested is 1200 mg/day or less≤ 1200 mg/day

Yes/No checkbox

Dose requested is 12 g/day or less

Attestation: Prescriber attests that member does not have adrenal cortical insufficiency

Attestation signature required

60 mg every 4 weeks for the diagnosis of acromegaly60 mg every 4 weeks