CurrentColorado Rocky Mountain Health PlansPolicy N/A

Isturisa (osilodrostat) prior authorization

Defines prior authorization requirements for Isturisa (osilodrostat) for treatment of endogenous Cushing's syndrome in adults; applies to providers submitting pharmacy prior authorization requests to UnitedHealthcare Pharmacy Clinical Pharmacy Programs.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyIsturisa (osilodrostat) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionSubmit documentation that the patient has Cushing's syndrome and is not a candidate for pituitary surgery or that surgery was not curative to request initial authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 moauthorization duration

Isturisamedication

Prior Authprogram type

Coverage Criteria

inv-01: Initial Therapy

Covered when ALL of the following are met:

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Initial Authorization

Diagnosis of Cushing's syndrome
Surgery status
- Not a candidate for surgery: Patient is not a candidate for pituitary surgery
- Surgery not curative: Pituitary surgery has not been curative

Initial Authorization (concise): Diagnosis of Cushing's syndrome AND patient is not a candidate for pituitary surgery OR pituitary surgery has not been curative

Authorization will be issued for 12 months

Supply limits and other utilization management controls may apply to Isturisa (osilodrostat). UnitedHealthcare may use automated approval and reapproval processes that rely on previous claim/medication history, diagnosis codes (ICD-10), and claim logic; the use of these automated processes varies by program and therapeutic class. Providers should be aware that supply limits may be enforced in addition to the clinical coverage criteria.

Provider Actions and Documentation

Prior Authorization

Initial authorization criteria

Initial authorization requires a diagnosis of Cushing's syndrome and documentation related to pituitary surgery candidacy; authorizations are issued for 12 months.

Diagnosis: Cushing's syndrome required
AND one of the following:
• Patient is not a candidate for pituitary surgery
• Pituitary surgery has not been curative
Authorization duration: 12 months

Prior Authorization

Reauthorization criteria

Reauthorization requires documentation of a positive clinical response to therapy; approvals are issued for 12 months. State or federal mandates and the member's benefit plan may affect coverage.

Documentation of positive response to Isturisa therapy required
Authorization duration: 12 months
Note: State mandates, federal requirements, and member benefit plan coverage may impact criteria

Note

Automated approval and supply limits

Automated approval and supply limits may apply. Approvals (initial or reauthorization) can be granted based on previous claims/medication history, diagnosis codes (ICD-10), and claim logic where programmatic automated processes are used.

Automated approvals may rely on claims/medication history and ICD-10 diagnosis codes
Use of automated approval/re-approval processes varies by program or therapeutic class
Supply limits may be in place

Documentation Required

Required documentation and authorization triggers

Required documentation must be maintained and provided for both initial authorization and reauthorization requests. Missing required documentation or failure to demonstrate surgical candidacy/curative surgery when applicable may trigger denial.

Clinical records supporting diagnosis of Cushing's syndrome
Documentation regarding pituitary surgery candidacy or outcomes (if applicable)
Documentation of positive clinical response for reauthorization
Be aware: absence of required documentation may lead to denial; state/federal mandates and the member's benefit plan may also affect requirements

Definitions

Not a candidate for pituitary surgery / Pituitary surgery not curative — definition and clinical determination

DefinitionClinical determination that the patient cannot undergo pituitary surgery or has persistent hypercortisolemia after pituitary surgery, qualifying them for medical therapy with Isturisa.

Documentation requiredProvider must document either that the patient is not a candidate for pituitary surgery OR that pituitary surgery was not curative (persistent hypercortisolemia).

Related coverage consequenceMeeting this determination is one of the required criteria for initial authorization of Isturisa; approvals are issued for 12 months.

Clinical contextIsturisa is indicated for adults with Cushing's syndrome when surgery is not an option or was not curative; this determination identifies patients appropriate for medical therapy.

Authorization logicInitial approval requires a diagnosis of Cushing's syndrome AND either 'not a candidate for pituitary surgery' OR 'pituitary surgery has not been curative'.