Isturisa (osilodrostat phosphate) — Blue Cross Blue Shield of Montana

Cushing’s syndrome

Initial criteria

Patient has a diagnosis of Cushing’s syndrome AND
Patient had an inadequate response to surgery OR is not a candidate for surgery AND disease is persistent or recurrent as evidenced by ONE of the following: mean of three 24-hour urine free cortisol (UFC) >1.3 times upper limit of normal OR morning plasma ACTH above the lower limit of normal
Prescriber is a specialist in endocrinology or has consulted a specialist
Patient will not be using the requested agent in combination with glucocorticoid replacement therapy
Patient does not have any FDA labeled contraindications to the requested agent
ONE of the following: patient has advanced stage IV metastatic cancer and Isturisa is used to treat it or an associated condition OR patient is currently stable on Isturisa OR the patient has tried and had inadequate response, discontinuation due to AE or diminished effect, intolerance, contraindication, or clinical infeasibility to at least ONE of mifepristone, pasireotide (Signifor/Signifor LAR), levoketoconazole (Recorlev), cabergoline, metyrapone, or mitotane (Lysodren) AND also has tried and failed or cannot take ketoconazole tablets under same conditions
If the patient has an FDA labeled indication: patient’s age is within labeling OR supported by evidence for use at that age

Patient previously approved through plan’s prior authorization process
Patient has had clinical benefit with Isturisa
Prescriber is a specialist in endocrinology or has consulted a specialist
Patient will not be using the requested agent in combination with glucocorticoid replacement therapy
Patient does not have any FDA labeled contraindications to the requested agent

12 months