By Counterforce Health Team in Natpara (parathyroid hormone) —

How to Get Natpara (Parathyroid Hormone) Covered by Aetna in Georgia: Complete Prior Authorization Guide

Answer Box: Getting Natpara Covered by Aetna in Georgia

Critical Update: Takeda discontinued manufacturing Natpara globally at the end of 2024. No new commercial prescriptions are being filled—only existing Special Use Program patients continue to receive supply until December 31, 2025. If you're seeking Natpara coverage, work with your endocrinologist to transition to alternative treatments like high-dose calcium and calcitriol. For existing patients, contact your provider immediately to develop a long-term treatment plan before supply ends.

For historical reference or alternative hypoparathyroidism treatments requiring Aetna prior authorization in Georgia: submit via Aetna's provider portal with complete lab documentation, exhaust internal appeals if denied, then file external review with Georgia DOI within 60 days.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Critical Supply Information
  3. Understanding Aetna's Coverage Requirements
  4. Gather Required Documentation
  5. Submit Your Prior Authorization Request
  6. Follow-Up and Timeline Expectations
  7. If Denied: Georgia Appeals Process
  8. Alternative Treatment Options
  9. FAQ: Common Questions
  10. Sources and Further Reading

What This Guide Covers

This guide helps patients with hypoparathyroidism and their healthcare providers navigate Aetna's coverage process for Natpara (parathyroid hormone) in Georgia. While Natpara is no longer commercially available due to Takeda's manufacturing discontinuation, understanding these requirements remains valuable for:

  • Existing Special Use Program patients seeking coverage documentation
  • Patients transitioning to alternative therapies requiring prior authorization
  • Healthcare providers preparing for future hypoparathyroidism treatments

Who this helps: Patients with confirmed hypoparathyroidism, their caregivers, endocrinologists, and specialty pharmacy staff working with Aetna coverage in Georgia.

Before You Start: Critical Supply Information

Natpara Availability Status (2024-2025)

Manufacturing discontinued: Takeda permanently ceased global manufacturing at the end of 2024 due to unresolved particle contamination issues from injection cartridges.

Current access: Only patients already enrolled in the U.S. Special Use Program (established after the 2019 recall) continue receiving supply while inventory lasts.

Program closure: All shipments and the Special Use Program will cease December 31, 2025, with no further supply available.

Important: If you're currently receiving Natpara through the Special Use Program, work with your endocrinologist immediately to develop an alternative treatment plan. Don't wait until 2025.

Verify Your Plan Details

Before pursuing any prior authorization:

  • Check your plan type: Commercial, Medicare Advantage, or Medicaid managed care
  • Confirm specialty pharmacy: Most Aetna plans route specialty medications through CVS Caremark
  • Review formulary status: Access your plan's drug list at Aetna.com or call member services

Understanding Aetna's Coverage Requirements

Medical Necessity Criteria for Natpara

Based on Aetna's clinical policy, coverage requires:

Confirmed diagnosis documentation:

  • Hypocalcemia and low serum parathyroid hormone (PTH) levels
  • Lab values documented on at least 2 separate dates, minimum 21 days apart within the last 12 months

Current therapy requirements:

  • Vitamin D metabolite/analog therapy (calcitriol ≥0.25 mcg/day or alfacalcidol ≥0.5 mcg/day)
  • Supplemental calcium ≥1000 mg/day in addition to normal dietary intake

Laboratory prerequisites:

  • Normal serum magnesium levels within lab limits
  • Serum 25-hydroxyvitamin D above the lower limit of normal
  • Serum calcium level >7.5 mg/dL before starting Natpara

Continuation criteria: Evidence of clinical benefit through maintenance or normalization of calcium levels compared to baseline.

ICD-10 Codes for Documentation

Use the most specific code supported by your clinical documentation:

ICD-10 Code Description When to Use
E20.810 Autosomal dominant hypocalcemia CASR mutation confirmed by genetic testing
E89.2 Postprocedural hypoparathyroidism Chronic, after surgical procedures
E20.812 Autoimmune hypoparathyroidism Autoimmune etiology, lab-confirmed
E20.819 Hypoparathyroidism, unspecified Etiology unclear, low calcium/low PTH confirmed

Gather Required Documentation

Essential Documents Checklist

Laboratory results (within 12 months):

  • Serum calcium levels (at least 2 dates, 21+ days apart)
  • Parathyroid hormone (PTH) levels
  • Serum magnesium (normal range)
  • 25-hydroxyvitamin D levels
  • Serum phosphate levels

Clinical documentation:

  • Endocrinologist consultation notes
  • Current medication list with doses
  • Documentation of prior treatment failures or contraindications
  • Surgical history (if postprocedural hypoparathyroidism)

Insurance information:

Clinician Corner: Medical Necessity Letter

When preparing documentation for alternative treatments, include:

  1. Clear diagnosis: Specific type of hypoparathyroidism with ICD-10 code
  2. Prior therapy history: Detailed record of conventional treatments tried and outcomes
  3. Clinical rationale: Why standard therapy is insufficient or contraindicated
  4. Treatment goals: Specific calcium targets and monitoring plan
  5. Literature support: Reference FDA labeling and endocrine society guidelines where applicable

Submit Your Prior Authorization Request

Submission Process

For Aetna commercial plans:

  1. Online: Submit via Aetna provider portal (verify current link at Aetna.com)
  2. Phone: Call 1-888-632-3862 (TTY: 711) for commercial plans
  3. Fax: Use number provided in your plan's provider manual

For Medicare Advantage plans:

  • Call 1-800-624-0756 (TTY: 711)
  • Submit requests at least 2 weeks in advance when possible

Clean Request Packet Tips

  • Complete forms: Fill all required fields; incomplete requests cause delays
  • Organize attachments: Label each document clearly (Lab Results, Clinical Notes, etc.)
  • Include cover letter: Brief summary of diagnosis, prior treatments, and medical necessity
  • Track submission: Note confirmation numbers and submission dates

Follow-Up and Timeline Expectations

Standard Processing Times

Aetna decision timeframes:

  • Standard prior authorization: 30-45 days
  • Expedited/urgent requests: ≤72 hours (Medicare ≤72 hours)
  • Complex cases requiring peer review: May extend to maximum allowable time

When and How to Follow Up

Day 7-10: Call to confirm receipt and completeness of your submission Day 20: Check status if no decision received Day 30: Escalate if approaching deadline without decision

Sample follow-up script: "I'm calling to check the status of prior authorization request #[number] for [patient name] submitted on [date]. Can you confirm it's complete and provide an expected decision date?"

If Denied: Georgia Appeals Process

Internal Appeals with Aetna

First step: File internal appeal within 180 days of denial notice

  • Submit via member portal or mail to address on denial letter
  • Include all original documentation plus any new supporting evidence
  • Request peer-to-peer review if clinical disagreement exists

Georgia External Review Process

If Aetna's internal appeal is denied, you have 60 days from the final denial letter to request external review through the Georgia Department of Insurance.

Key facts:

  • Cost: Free to consumers
  • Timeline: Standard review within 30 business days; expedited ≤72 hours for urgent cases
  • Decision: Binding on Aetna
  • Contact: Georgia DOI at 1-800-656-2298

How to file:

  1. Complete Georgia DOI external review form (available on DOI website)
  2. Submit denial letters and medical documentation
  3. File within 60-day deadline from final Aetna denial
From our advocates: Many specialty drug denials in Georgia are overturned through external review when complete medical documentation clearly demonstrates necessity and prior treatment failures. The key is thorough documentation and meeting all deadlines.

Alternative Treatment Options

Since Natpara is no longer available, work with your endocrinologist on these alternatives:

Standard Therapy Options

  • High-dose calcium supplements: Multiple daily doses to maintain serum levels
  • Active vitamin D analogs: Calcitriol or alfacalcidol for enhanced calcium absorption
  • Monitoring protocols: Frequent lab checks to adjust dosing and prevent complications

Emerging Treatments

  • Teriparatide: Some clinicians consider off-label use (verify coverage requirements)
  • Clinical trials: Check ClinicalTrials.gov for investigational treatments

Financial Assistance

  • Contact patient advocacy organizations for support programs
  • Explore state pharmaceutical assistance programs in Georgia
  • Check manufacturer copay cards for alternative medications

FAQ: Common Questions

Q: How long does Aetna prior authorization take in Georgia? A: Standard requests: 30-45 days. Expedited/urgent requests: ≤72 hours. Processing may be faster if all documentation is complete upon submission.

Q: What if my medication is non-formulary? A: Request a formulary exception with medical necessity documentation. Include evidence that formulary alternatives are inappropriate or ineffective.

Q: Can I request an expedited appeal in Georgia? A: Yes, both Aetna and Georgia's external review process offer expedited options when delays could seriously jeopardize your health.

Q: Does step therapy apply if I've failed treatments outside Georgia? A: Yes, document prior treatment failures from any location. Include medical records showing specific medications tried, duration, and reasons for discontinuation.

Q: What happens after December 31, 2025? A: No Natpara supply will be available after this date. Work with your healthcare provider now to establish effective alternative treatment regimens.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that align with each payer's specific requirements. For complex prior authorization challenges, we provide the documentation and advocacy tools needed to secure coverage for essential medications.

Sources and Further Reading

This guide is for informational purposes only and does not constitute medical advice. Always consult with your healthcare provider for medical decisions. Insurance coverage requirements may change; verify current policies with your insurer. For assistance with insurance appeals in Georgia, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

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