By Counterforce Health Team in Natpara (parathyroid hormone) —

How to Get Natpara (Parathyroid Hormone) Covered by Aetna CVS Health in Illinois: Complete 2025 Guide

Quick Answer: Getting Natpara Covered by Aetna CVS Health in Illinois

Important Update: Takeda discontinued Natpara manufacturing globally at the end of 2024, with U.S. Special Use Program shipments ending December 31, 2025. New starts are typically denied due to lack of commercial supply. Only existing patients enrolled in Takeda's Special Use Program may receive coverage.

For existing patients: Submit prior authorization with documented hypoparathyroidism, failed calcium/vitamin D therapy, and specialist consultation. Use Aetna's precertification form and expect 30-45 day decisions. If denied, Illinois residents have strong appeal rights including automatic external review after internal appeal denial.

First step: Contact your endocrinologist to verify Special Use Program enrollment and gather required documentation.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Checklist
  4. Documentation Requirements
  5. Submission Process
  6. Specialty Pharmacy Coordination
  7. After Submission: What to Expect
  8. Appeals Process in Illinois
  9. Common Denial Reasons & Solutions
  10. Cost Assistance Options
  11. FAQ

Who Should Use This Guide

This guide is designed for Illinois residents with Aetna CVS Health coverage who need Natpara (parathyroid hormone) for chronic hypoparathyroidism. Given the medication's discontinuation, this primarily applies to:

  • Existing Natpara patients enrolled in Takeda's Special Use Program
  • Clinicians managing these patients through the transition period
  • Caregivers helping navigate insurance requirements

Expected outcome: Understanding how to maintain coverage through December 2025 and prepare for transition to alternative therapies.

Member & Plan Basics

Coverage Requirements

  • Active Aetna CVS Health plan (commercial, Medicare Advantage, or Medicaid)
  • Prior authorization required for all Natpara requests
  • Specialty pharmacy benefit through CVS Specialty or approved network
Note: Verify your plan's specialty drug coverage by calling the member services number on your insurance card.

Plan Type Considerations

Different Aetna plan types may have varying requirements:

  • Commercial plans: Standard PA process, 30-45 day decisions
  • Medicare Advantage: May have expedited timelines (≤72 hours for urgent)
  • Medicaid: State-specific formulary requirements apply

Clinical Criteria Checklist

Required Diagnosis Documentation

✓ Confirmed hypoparathyroidism with appropriate ICD-10 code:

  • E20.0: Idiopathic hypoparathyroidism
  • E20.8: Other hypoparathyroidism
  • E20.9: Hypoparathyroidism, unspecified
  • E89.2: Postprocedural hypoparathyroidism

✓ Laboratory evidence on at least 2 separate dates >21 days apart within past 12 months:

  • Low serum calcium
  • Low or inappropriately normal parathyroid hormone (PTH)

Step Therapy Requirements

✓ Documented failure, intolerance, or inadequate response to BOTH:

  • Calcium supplementation: ≥1000 mg/day in addition to dietary intake
  • Active vitamin D therapy: Calcitriol ≥0.25 mcg/day or alfacalcidol ≥0.5 mcg/day

Prerequisites Before Starting

✓ Normal serum magnesium ✓ Sufficient 25-hydroxyvitamin D (above lower limit of normal) ✓ Baseline serum calcium >7.5 mg/dL

Documentation Requirements

Medical Necessity Letter Components

Your endocrinologist should include:

  1. Patient identification and diagnosis with ICD-10 code
  2. Clinical history of hypoparathyroidism and symptoms
  3. Prior therapy details with specific doses and durations
  4. Documented treatment failures with lab values and dates
  5. Rationale for Natpara necessity
  6. Treatment goals and monitoring plan

Required Attachments

  • Recent laboratory results (calcium, PTH, magnesium, vitamin D)
  • Endocrinologist consultation notes
  • Medication history documentation
  • Surgical history (if post-procedural hypoparathyroidism)
  • Completed Aetna precertification form
Clinician Corner: Reference the FDA-approved indication and include specific lab values showing inadequate control on maximum tolerated conventional therapy. Quantify symptoms and their impact on quality of life.

Submission Process

Step-by-Step: Fastest Path to Approval

  1. Verify Special Use Program enrollment with Takeda (existing patients only)
  2. Complete Aetna's precertification form using the official PDF
  3. Gather all required documentation (see checklist above)
  4. Submit via provider portal or fax (verify current contact information)
  5. Obtain confirmation number and track submission status
  6. Follow up within 2 weeks if no response received

Submission Channels

  • Online: Aetna provider portal or Availity
  • Phone: 1-888-632-3862 (commercial), 1-800-624-0756 (Medicare Advantage)
  • Fax: As listed in current plan documentation (verify with source linked below)

Specialty Pharmacy Coordination

CVS Specialty Network

Natpara is a Limited Distribution Drug (LDD) available only through select specialty pharmacies including CVS Specialty.

Transfer Process:

  1. Contact CVS Specialty: 1-800-237-2767
  2. Provide prescription and insurance information
  3. Complete patient onboarding including injection training
  4. Coordinate delivery and refill scheduling
Tip: CVS Specialty staff can help coordinate prior authorization submission and follow up on approval status.

After Submission: What to Expect

Timeline Expectations

  • Standard decisions: 30-45 days
  • Expedited reviews: ≤72 hours (if urgent medical need)
  • Confirmation: Should receive acknowledgment within 5 business days

What to Track

  • Confirmation number
  • Review status updates
  • Required additional information requests
  • Decision notification method (mail, portal, phone)

Appeals Process in Illinois

Illinois residents have strong appeal rights when Aetna denies coverage.

Internal Appeal Process

  1. File within 180 days of denial notice
  2. Submit appeal letter with supporting documentation
  3. Expect decision within 30 days (expedited: 72 hours)

External Review (Automatic as of 2025)

  • Automatic referral after internal appeal denial (unless you opt out)
  • Independent physician review by specialist in relevant field
  • Binding decision within 45 days (expedited: 72 hours)
  • No cost to patient

Illinois Resources

  • Illinois Department of Insurance: External review process
  • Consumer helpline: 877-527-9431
  • Attorney General Health Care Bureau: 1-877-305-5145

For patients navigating complex insurance denials, Counterforce Health helps turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and drafting point-by-point rebuttals aligned to each plan's specific policies.

Common Denial Reasons & Solutions

Denial Reason Solution
No commercial supply Verify Special Use Program enrollment; provide Takeda documentation
Step therapy not met Submit detailed prior therapy records with doses, durations, and outcomes
Non-formulary status Request formulary exception with medical necessity documentation
Insufficient documentation Provide complete lab results, specialist notes, and treatment history
Not medically necessary Include peer-reviewed evidence and guideline references supporting use

Cost Assistance Options

Manufacturer Support

  • Takeda Patient Services: May provide assistance for eligible patients in Special Use Program
  • Verify current programs as discontinuation affects availability

Foundation Resources

  • Patient Advocate Foundation: General medication assistance
  • National Organization for Rare Disorders (NORD): Rare disease support
Note: With Natpara's discontinuation, focus on transition planning to alternative therapies that may have different assistance programs.

FAQ

Q: Can new patients get Natpara covered by Aetna in Illinois? A: No. Takeda discontinued manufacturing globally, and new starts are typically denied due to lack of commercial supply.

Q: How long do existing patients have access? A: The U.S. Special Use Program ends December 31, 2025. All patients must transition to alternative therapies.

Q: What happens if my internal appeal is denied? A: Illinois law requires automatic referral to external review unless you opt out. An independent specialist will review your case.

Q: Can I request expedited review? A: Yes, if delay would seriously jeopardize your health. Your doctor must certify the urgent need.

Q: What alternatives exist to Natpara? A: Management typically involves optimized calcium and vitamin D therapy. Some clinicians consider off-label teriparatide where appropriate.

Q: How do I file an external review in Illinois? A: Use the Illinois Department of Insurance portal or contact their helpline at 877-527-9431.

Sources & Further Reading

Disclaimer: This guide provides general information and should not replace professional medical or legal advice. Insurance policies and state regulations may change. Always verify current requirements with your insurer and healthcare providers. For personalized assistance with insurance appeals, consider consulting with healthcare advocates who specialize in coverage denials.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate insurance denials by creating targeted appeals that align with each payer's specific policies and requirements.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.