By Counterforce Health Team in Nourianz (istradefylline) —

Complete Checklist to Get Nourianz (istradefylline) Covered by Humana in Virginia: Forms, Appeals, and Approval Steps

Answer Box: Getting Nourianz Covered by Humana in Virginia

Nourianz (istradefylline) requires prior authorization from Humana for Parkinson's disease OFF episodes. The fastest path: 1) Confirm your doctor has documented failed trials of other adjunct therapies (amantadine, MAO-B inhibitors, or COMT inhibitors), 2) Submit PA request via Humana's provider portal with detailed OFF episode documentation, and 3) If denied, file internal appeal within 65 days. Virginia residents can pursue external review through federal Medicare appeals (not state review) if internal appeals fail.

Table of Contents

Who Should Use This Checklist

This comprehensive checklist is designed for Virginia patients with Humana Medicare Advantage or Part D coverage who need Nourianz (istradefylline) for Parkinson's disease OFF episodes, along with their healthcare providers and caregivers.

Expected outcome: Following this checklist systematically increases your chances of initial approval and helps you navigate denials effectively. Counterforce Health helps patients and providers turn insurance denials into successful appeals by creating evidence-backed letters that address specific payer requirements and denial reasons.

Use this guide if you:

  • Have been prescribed Nourianz for Parkinson's disease OFF episodes
  • Hold active Humana Medicare Advantage or Part D coverage in Virginia
  • Need to submit a prior authorization request or appeal a denial
  • Want to understand Virginia-specific appeal rights and timelines

Member & Plan Basics

Coverage Verification

Before starting your prior authorization request, confirm these essential details:

✓ Active Humana Coverage

  • Verify your Humana Medicare Advantage or Part D plan is active
  • Check your member ID and group number on your insurance card
  • Confirm Virginia as your coverage state

✓ Plan Type & Benefits

  • Medicare Advantage: Integrated medical and prescription coverage
  • Part D: Prescription drug coverage (may be standalone or integrated)
  • Deductible status: Check if you've met your annual deductible

✓ Prior Authorization Requirements Humana requires prior authorization for Nourianz across most Medicare plans. Check your plan's formulary to confirm current status and tier placement.

Clinical Criteria Requirements

Primary Indication

✓ Parkinson's Disease Diagnosis

  • Confirmed diagnosis of idiopathic Parkinson's disease
  • Currently treated with levodopa/carbidopa (stable regimen)
  • Experiencing motor fluctuations ("OFF" episodes)

Step Therapy Documentation

Humana typically requires documented trials and failures of other adjunctive therapies before approving Nourianz:

✓ Required Prior Therapies (document failures/intolerance):

  • MAO-B inhibitors: Rasagiline, selegiline, or safinamide
  • COMT inhibitors: Entacapone, opicapone, or tolcapone
  • Dopamine agonists: Pramipexole, ropinirole, or rotigotine
  • Amantadine: Immediate or extended-release formulations

OFF Episode Documentation

✓ Detailed characterization required:

  • Frequency: How often OFF episodes occur daily
  • Duration: Typical length of each OFF episode
  • Type: Early morning, end-of-dose, unpredictable, or delayed ON
  • Impact: Functional limitations during OFF periods
  • Patient diary: Consider symptom logs to support documentation

Coding & Documentation Requirements

ICD-10 Diagnosis Codes

✓ Use updated Parkinson's codes (effective October 2023):

  • G20.A2: Parkinson's disease without dyskinesia, with fluctuations
  • G20.B2: Parkinson's disease with dyskinesia, with fluctuations

Drug Coding

✓ Nourianz billing information:

  • NDC: Use current manufacturer NDC (verify with Nourianz.com)
  • No HCPCS J-code: Nourianz is oral medication, not injectable
  • Dosing: 20mg or 40mg once daily

Documentation Packet Essentials

Provider Note Requirements

✓ Essential elements for medical necessity:

  1. Diagnosis confirmation: Parkinson's disease with motor fluctuations
  2. Current medications: Levodopa/carbidopa dosing and schedule
  3. OFF episode details: Frequency, duration, and functional impact
  4. Prior therapy trials: Specific medications tried, duration, and reason for discontinuation
  5. Clinical rationale: Why Nourianz is appropriate for this patient
  6. Monitoring plan: How response will be assessed

Letter of Medical Necessity Components

✓ Include these sections:

  • Patient demographics and insurance information
  • Detailed diagnosis with ICD-10 codes
  • Comprehensive medication history
  • OFF episode burden documentation
  • Step therapy compliance documentation
  • Expected benefits and monitoring plan
  • Provider signature and contact information

Required Attachments

✓ Gather these documents:

  • Recent clinic notes (last 3-6 months)
  • Medication trial documentation
  • Patient symptom diary (if available)
  • Previous denial letters (if appealing)
  • Lab results or imaging (if relevant)

Submission Process

Prior Authorization Submission

✓ Submit via Humana provider portal:

  1. Access Humana's provider portal
  2. Complete all required fields accurately
  3. Upload comprehensive documentation packet
  4. Verify submission confirmation number

✓ Alternative submission methods:

  • Phone: Interactive voice response system (verify current number with Humana)
  • Fax: Check current fax number on provider portal

Timeline Expectations

  • Standard review: Up to 30 days for Part C decisions
  • Expedited review: 72 hours if medically urgent
  • Part D appeals: 7 days standard, 72 hours expedited

Specialty Pharmacy Requirements

Limited Distribution Network

Nourianz is only available through three specialty pharmacy networks:

✓ Approved dispensing locations:

  • Walgreens Specialty Pharmacy
  • CVS Specialty Pharmacy
  • Accredo Specialty Pharmacy
Note: Even Humana members must use these designated specialty pharmacies, not CenterWell Specialty Pharmacy, due to manufacturer distribution restrictions.

Prescription Transfer Process

✓ Steps for specialty pharmacy setup:

  1. Provider sends prescription to approved specialty pharmacy
  2. Specialty pharmacy contacts patient for insurance verification
  3. Pharmacy assists with copay program enrollment (if eligible)
  4. Medication shipped to home or available for pickup

After Submission: Tracking Your Request

Confirmation and Follow-up

✓ Record these details:

  • Prior authorization request number
  • Submission date and method
  • Expected decision timeline
  • Provider contact for follow-up

Status Monitoring

✓ Check request status:

  • Log into Humana member portal regularly
  • Call member services if no response within expected timeframe
  • Document all communications with reference numbers

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Step therapy not met Document failed trials of required medications Detailed medication history with reasons for discontinuation
Insufficient OFF episode documentation Provide comprehensive symptom diary and clinical notes Patient-reported outcome measures, functional assessments
Non-formulary status Request formulary exception Comparative effectiveness data, clinical rationale
Quantity limits exceeded Justify higher dose/frequency Clinical evidence supporting increased dosing
Missing concurrent levodopa Confirm stable levodopa regimen Current medication list with dosing

Appeals Process for Virginia Residents

Internal Appeals (First Level)

✓ Humana internal appeal process:

  • Deadline: 65 days from denial notice
  • Method: Online portal, phone, or written request
  • Timeline: 30 days for standard, 72 hours for expedited
  • Required: Original denial letter, additional medical evidence

External Review Options

Important: Medicare Advantage plans follow federal appeal procedures, not Virginia state external review.

✓ Federal Medicare appeals process:

  1. Level 2: Independent Review Entity (IRE)
  2. Level 3: Administrative Law Judge
  3. Level 4: Medicare Appeals Council
  4. Level 5: Federal District Court
Virginia-specific note: While Virginia's State Corporation Commission Bureau of Insurance provides external review for state-regulated plans, Medicare Advantage appeals are handled under federal jurisdiction through CMS procedures.

When to Seek Help

✓ Consider professional assistance if:

  • Multiple denials despite complete documentation
  • Complex medical history requiring specialized appeal language
  • Approaching appeal deadlines with insufficient time

Counterforce Health specializes in transforming insurance denials into successful appeals by creating targeted, evidence-backed letters that address specific payer requirements and denial reasons.

Costs & Patient Assistance

Expected Costs

  • Cash price: Approximately $1,900-$2,100 per 30-day supply
  • Humana coverage: Varies by plan tier and deductible status

Financial Assistance Options

✓ Available support programs:

  • Manufacturer copay assistance: Check eligibility at Nourianz.com
  • Medicare limitations: Copay cards cannot be used with Medicare
  • Foundation grants: Research Parkinson's-specific assistance programs
  • State programs: Virginia may offer additional prescription assistance

Frequently Asked Questions

Q: How long does Humana prior authorization take for Nourianz? A: Standard reviews take up to 30 days. Expedited reviews (when medically urgent) are completed within 72 hours.

Q: What if Nourianz isn't on Humana's formulary? A: Request a formulary exception by providing clinical documentation showing why Nourianz is medically necessary compared to covered alternatives.

Q: Can I get an expedited appeal in Virginia? A: Yes, if your doctor certifies that delays could seriously harm your health. Expedited appeals are decided within 72 hours.

Q: Do I need to try specific medications before Nourianz? A: Yes, Humana typically requires documented trials of MAO-B inhibitors, COMT inhibitors, or amantadine before approving Nourianz.

Q: Where can I fill my Nourianz prescription? A: Only at Walgreens, CVS, or Accredo specialty pharmacies due to manufacturer distribution restrictions.

Q: What happens if my appeal is denied? A: Medicare Advantage members can continue to higher levels of federal appeals, including Independent Review Entity and Administrative Law Judge reviews.

From our advocates: We've seen many Nourianz approvals succeed when providers document specific OFF episode patterns—like "patient experiences 2-3 hour morning OFF periods daily despite optimized levodopa timing"—rather than general statements about motor fluctuations. This concrete detail helps reviewers understand the functional impact and medical necessity.

Printable Checklist: Quick Reference

Before Submission:

  • Confirm active Humana coverage and plan type
  • Document Parkinson's diagnosis with motor fluctuations
  • Record failed trials of required step therapy medications
  • Gather detailed OFF episode documentation
  • Prepare comprehensive medical necessity letter
  • Identify appropriate specialty pharmacy for dispensing

During Submission:

  • Submit via Humana provider portal with all attachments
  • Record confirmation number and expected timeline
  • Verify specialty pharmacy has received prescription
  • Schedule follow-up for status check

If Denied:

  • Review denial reason carefully
  • Gather additional supporting documentation
  • Submit internal appeal within 65 days
  • Consider expedited review if medically urgent
  • Prepare for potential external federal appeals

Disclaimer: This guide provides educational information about insurance coverage processes and should not be considered medical or legal advice. Coverage decisions depend on individual circumstances, plan benefits, and medical necessity. Always consult with your healthcare provider about treatment options and work with qualified professionals for complex appeal situations.

For additional help with Virginia insurance issues, contact the Virginia State Corporation Commission Bureau of Insurance at 1-877-310-6560.

Sources & Further Reading

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