Subject: Isturisa 3667-A SGM P2021
Policy:
I. INDICATIONS
The indications below including FDA-approved indications and compendial uses are considered a covered benefit provided that all the approval criteria are met and the member has no exclusions to the prescribed therapy.
FDA-Approved Indications
Isturisa is indicated for the treatment of adult patients with Cushing’s disease for whom pituitary surgery is not an option or has not been curative.
All other indications are considered experimental/investigational and not medically necessary.
II. DOCUMENTATION
Cushing’s syndrome/disease
Submission of the following information is necessary to initiate the prior authorization review:
A. For initial requests, either of the following:
1. Pretreatment urinary free cortisol (UFC) level
2. One of the following if UFC level is not an appropriate measure due to the member’s condition (e.g., renal insufficiency/failure, adrenal incidentaloma)
a. Pretreatment late-night salivary cortisol
b. Pretreatment 1 mg overnight dexamethasone suppression test (DST)
c. Pretreatment longer, low dose DST (2mg per day for 48 hours)
B. For continuation of therapy, either of the following:
1. Current urinary free cortisol (UFC) level
2. One of the following if UFC level is not an appropriate measure due to the member’s condition (e.g., renal insufficiency/failure, adrenal incidentaloma)
a. Current late-night salivary cortisol
b. Current 1 mg overnight dexamethasone suppression test (DST)
c. Current longer, low dose DST (2mg per day for 48 hours)
III. CRITERIA FOR INITIAL APPROVAL
Cushing’s syndrome/disease
Authorization of 6 months may be granted for treatment of Cushing’s syndrome/disease in members who either have had surgery that was
not curative OR for members who are not candidates for surgery.
IV. CONTINUATION OF THERAPY
Cushing’s syndrome/disease
Authorization of 12 months for continuation of therapy may be granted for members that meet one of the following criteria:
A. Lower urinary free cortisol levels since the start of therapy
B. Lower cortisol levels since the start of therapy per one of the following tests (if UFC is not an appropriate measure due to the member’s condition):
1. Late-night salivary cortisol
2. 1 mg overnight dexamethasone suppression test (DST)
3. Low dose DST (2mg per day for 48 hours)
C. Improvement in signs and symptoms of the disease
Place of Service:
Outpatient
The above policy is based on the following references:
- Isturisa [package insert]. Lebanon, NJ: Recordati Rare Disease, Inc.; March 2020.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
August 20, 2021
