By Counterforce Health Team in Nourianz (istradefylline) —

Get Nourianz (Istradefylline) Covered by Humana in Ohio: Complete PA Guide & Appeals

Answer Box: Quick Path to Coverage

Nourianz (istradefylline) requires prior authorization from Humana Medicare plans in Ohio. You'll need documented Parkinson's disease with "off" episodes (≥2 hours daily) while on stable carbidopa/levodopa therapy. First step today: Have your neurologist submit a PA request through Humana's provider portal with complete clinical documentation. If denied, you have 60 days to request a redetermination (internal appeal), followed by Medicare's federal appeals process. Standard PA decisions take up to 30 days; expedited reviews are available for urgent cases.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Deadlines
  4. Medical Necessity Criteria
  5. Costs and Pharmacy Options
  6. Denials and Appeals
  7. Renewal Requirements
  8. Specialty Pharmacy Network
  9. Troubleshooting Common Issues
  10. Resources and Next Steps

Coverage Basics

Is Nourianz covered by Humana in Ohio? Yes, but with restrictions. Nourianz (istradefylline) appears on select Humana Medicare formularies as a covered medication, typically placed on higher tiers (Tier 4 or 5) requiring prior authorization and potentially specialty pharmacy dispensing.

Which Humana plans cover it? Most Humana Medicare Advantage and standalone Part D plans include Nourianz on their formularies, but exact tier placement and cost-sharing vary by plan. You can verify your specific coverage by logging into your MyHumana account or using their drug lookup tool.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Humana plans Provider portal PA lists
Step Therapy Must try alternatives first Plan formulary documents
Formulary Tier Usually Tier 4-5 (high cost) MyHumana drug lookup
Specialty Pharmacy Often required CenterWell Specialty Pharmacy
Age Requirement 18+ years FDA prescribing information

Prior Authorization Process

Who submits the request? Your prescribing physician (preferably a neurologist) must submit the prior authorization request to Humana. Patients cannot submit PA requests directly.

How to submit:

  1. Provider portal: Most efficient method through Humana's online system
  2. Phone: Provider services line on your ID card
  3. Fax: Check current fax numbers in provider portal (verify with the source linked above)

Required documentation:

  • Parkinson's disease diagnosis with ICD-10 code
  • Documentation of "off" episodes (frequency, duration, symptoms)
  • Current carbidopa/levodopa regimen and duration
  • History of failed alternative therapies
  • Clinical notes supporting medical necessity
Clinician Corner: Your medical necessity letter should include: (1) specific "off" episode documentation with timing and impact on daily activities, (2) carbidopa/levodopa dosing history and stability, (3) prior adjunctive therapy trials with specific drugs, doses, and reasons for discontinuation, and (4) clinical rationale citing FDA prescribing information for istradefylline's role in managing motor fluctuations.

Timing and Deadlines

Standard prior authorization: Up to 30 days for Humana to make a decision after receiving complete documentation.

Expedited review: Available when a delay could seriously jeopardize your health. Your doctor must request this and provide clinical justification. Decision within 72 hours.

Appeal deadlines if denied:

  • Redetermination (first appeal): 60 days from denial notice
  • Reconsideration: 60 days from redetermination denial
  • Administrative Law Judge hearing: 60 days from reconsideration denial

Medical Necessity Criteria

Based on typical Humana policies and Medicare guidelines, Nourianz approval requires:

Essential requirements:

  • Confirmed Parkinson's disease diagnosis
  • Age 18 or older
  • Currently taking carbidopa/levodopa for ≥1 year
  • Stable levodopa dose for ≥4 weeks
  • Documented "off" episodes ≥2 hours per day
  • Prescription by or consultation with neurologist

Step therapy requirements: Most plans require documented failure, contraindication, or intolerance to at least two other adjunctive Parkinson's therapies from different classes:

  • MAO-B inhibitors: rasagiline, safinamide, selegiline
  • COMT inhibitors: entacapone, tolcapone, opicapone
  • Dopamine agonists: pramipexole, ropinirole, rotigotine
  • Amantadine: immediate or extended-release formulations

Documentation specifics:

  • Chart notes describing "off" episode characteristics
  • Medication history with specific drugs, doses, duration, and outcomes
  • Clinical assessment of functional impact

Costs and Pharmacy Options

Typical costs for Nourianz range from $1,900-$2,100 for a 30-day supply without insurance. With Humana coverage:

  • Tier 4: Usually 25-33% coinsurance after deductible
  • Tier 5: May be 25-33% coinsurance with higher cost-sharing

Savings options:

  • Manufacturer copay program: Kyowa Kirin offers patient assistance (verify eligibility at manufacturer website)
  • Foundation grants: Organizations like PAN Foundation may help with copays
  • CenterWell Specialty Pharmacy: May offer payment plans and financial counseling

Where to fill prescriptions: Nourianz typically requires specialty pharmacy dispensing through CenterWell Specialty Pharmacy (Humana's preferred specialty pharmacy) or other in-network specialty pharmacies.

Denials and Appeals

Common denial reasons and solutions:

Denial Reason How to Overturn
Incomplete step therapy Submit documentation of failed alternatives with specific drugs, doses, and outcomes
Missing "off" episode documentation Provide detailed chart notes with timing, frequency, and functional impact
Not on concurrent levodopa Confirm current carbidopa/levodopa regimen with prescription history
Insufficient specialist involvement Have neurologist submit or co-sign the request

Appeals process for Ohio residents:

Since Humana Medicare plans are federally regulated, appeals follow Medicare's process, not Ohio's state external review:

  1. Redetermination (internal appeal with Humana)
  2. Reconsideration by Independent Review Entity
  3. Administrative Law Judge hearing
  4. Medicare Appeals Council review
  5. Federal court review

How to file an appeal:

  • Use the appeal form included with your denial letter
  • Submit through your MyHumana account or mail to address on denial notice
  • Include all supporting documentation
  • Consider expedited appeals for urgent situations
From our advocates: We've seen Nourianz appeals succeed most often when the neurologist provides a detailed timeline showing how "off" episodes worsen despite optimized levodopa dosing and failed alternative therapies. Including patient-reported outcome measures and functional assessments strengthens the case significantly.

Renewal Requirements

Initial authorization: Typically granted for 12 months if all criteria are met.

Reauthorization requirements:

  • Evidence of positive clinical response to Nourianz
  • Continued use of carbidopa/levodopa therapy
  • Updated clinical assessment from neurologist
  • No significant adverse effects requiring discontinuation

When to start renewal process: Begin 30-60 days before current authorization expires to avoid treatment interruption.

Specialty Pharmacy Network

Why specialty pharmacy? Nourianz often requires specialty handling due to its cost, administration requirements, and need for patient education and monitoring.

Humana's preferred network: CenterWell Specialty Pharmacy provides:

  • Home delivery throughout Ohio
  • Clinical support and patient education
  • Insurance coordination and prior authorization assistance
  • Refill reminders and adherence support

Setting up specialty pharmacy:

  1. Your doctor sends prescription directly to CenterWell
  2. CenterWell contacts you to coordinate delivery
  3. Clinical pharmacists provide medication counseling
  4. Ongoing support for side effect management

Troubleshooting Common Issues

Portal problems: If Humana's provider portal is unavailable, providers can submit requests by phone or fax (verify current contact information through official channels).

Missing forms: All required forms are available through the Humana provider portal. Don't use outdated forms from other sources.

Status check: Track your PA request status through MyHumana member portal or by calling the member services number on your ID card.

Urgent situations: If you need Nourianz immediately while PA is pending, ask your doctor about requesting an expedited review with clinical justification for urgency.

Resources and Next Steps

For patients in Ohio:

  • Humana member services: Number on your ID card
  • Ohio Department of Insurance: 800-686-1526 for general insurance questions
  • Medicare appeals: 1-800-MEDICARE for federal appeals process

For healthcare providers:

Next steps today:

  1. Verify Nourianz is on your specific Humana formulary
  2. Gather required clinical documentation
  3. Have your neurologist submit the PA request with complete information
  4. Set up specialty pharmacy if approved

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed responses. Our platform analyzes denial letters and plan policies to identify specific approval pathways, then generates comprehensive appeals with the right clinical evidence and procedural requirements. For complex cases like Nourianz approvals, we help clinicians and patients navigate payer-specific workflows and documentation requirements to improve approval rates.

Important Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures can change. Always verify current requirements with Humana and consult your healthcare provider for medical decisions. For official appeals guidance, contact the Ohio Department of Insurance or Medicare directly.

Sources & Further Reading

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