By Counterforce Health Team in Natpara (parathyroid hormone) —

How to Get Natpara (Parathyroid Hormone) Covered by Blue Cross Blue Shield in Pennsylvania: Appeals Guide with Forms and Timelines

Answer Box: Getting Natpara Covered in Pennsylvania

Important Update: Takeda discontinued Natpara manufacturing globally, with the U.S. Special Use Program ending December 31, 2025. New prescriptions are typically denied due to lack of commercial supply. For existing patients transitioning off Natpara, Pennsylvania's external review program offers strong consumer protections with a 50% overturn rate for denied treatments.

Fastest Path for Coverage Appeals:

  1. File internal appeal with your Blue Cross Blue Shield plan within 180 days
  2. Use Pennsylvania's Independent External Review if denied (4-month window)
  3. Contact Pennsylvania Insurance Department for assistance

Table of Contents

  1. Why Pennsylvania State Rules Matter
  2. Turnaround Standards and Timelines
  3. Step Therapy Protections
  4. Continuity of Care Rights
  5. External Review and Complaints
  6. Practical Scripts and Appeals Language
  7. Limits and ERISA Plan Differences
  8. Quick Reference Resources
  9. FAQ

Why Pennsylvania State Rules Matter

Pennsylvania has significantly strengthened its health insurance appeals system, particularly benefiting patients with rare conditions like hypoparathyroidism. The state's Independent External Review Program, launched in January 2024, provides a powerful safety net when Blue Cross Blue Shield plans deny coverage.

How State and Plan Policies Interact

Blue Cross Blue Shield operates through independent plans in Pennsylvania—primarily Highmark Blue Shield (western PA) and Independence Blue Cross (Philadelphia region). While each plan maintains its own formularies and prior authorization criteria, all must comply with Pennsylvania's consumer protection laws.

Key Pennsylvania Advantages:

  • 50% overturn rate in external reviews (259 of 517 appeals succeeded in 2024)
  • State-supervised process (not federal default)
  • Clear 4-month window for external appeals
  • Strict insurer compliance requirements
Note: Self-funded employer plans may not be subject to all state protections, though many follow similar procedures voluntarily.

Turnaround Standards and Timelines

Pennsylvania law sets specific deadlines that Blue Cross Blue Shield must follow for prior authorization and appeals decisions.

Coverage at a Glance

Review Type Timeline When It Applies Filing Deadline
Standard PA Decision 15 days Pre-service requests N/A
Urgent PA Decision 72 hours Life/health threatening N/A
Internal Appeal (Standard) 30-60 days After denial 180 days from denial
Internal Appeal (Urgent) 48-72 hours Medical emergency 180 days from denial
External Review 45 days After internal denial 4 months from final denial
Expedited External Review 72 hours Urgent health threat 4 months from final denial

Source: Pennsylvania Insurance Department Appeals Guide

Calendar vs. Business Days

Pennsylvania uses calendar days for most deadlines, giving you more time than states using business days. However, verify specific requirements with your Blue Cross Blue Shield plan, as some internal processes may use business days.

Step Therapy Protections

Step therapy requires trying less expensive treatments before approving specialty medications. For hypoparathyroidism, this typically means demonstrating inadequate control with calcium and vitamin D supplementation.

Medical Exception Criteria

Pennsylvania law requires insurers to grant step therapy exceptions when:

  • The preferred drug is contraindicated
  • The preferred drug caused adverse effects
  • The preferred drug is expected to be ineffective
  • You're stable on the current medication

Documentation That Helps

For Natpara appeals, include:

  • Serum calcium levels showing inadequate control on calcium/vitamin D
  • Documentation of hypocalcemia symptoms (numbness, muscle cramps, seizures)
  • Evidence of complications (kidney stones, nephrocalcinosis)
  • Quality of life impact assessments
  • Any contraindications to high-dose calcium supplementation
Clinician Corner: Medical necessity letters should address each specific denial reason cited by BCBS. Include ICD-10 codes (E20.9 for hypoparathyroidism), failed therapy documentation, and cite FDA labeling for Natpara's approved indication.

Continuity of Care Rights

Pennsylvania provides strong continuity protections, especially important given Natpara's discontinuation timeline.

Ongoing Therapy Protections

If you're currently on Natpara through the Special Use Program:

  • Grace period: Plans must continue coverage during internal appeals
  • Transition planning: Insurers must work with providers on alternative treatments
  • Emergency supplies: Plans cannot abruptly discontinue during appeals

Renewal Timelines

For patients transitioning off Natpara by December 31, 2025:

  • Request coverage determination for alternative treatments 60 days before transition
  • Document current stability on Natpara
  • Establish baseline labs before switching therapies

External Review and Complaints

Pennsylvania's Independent External Review Program is your strongest tool for overturning Blue Cross Blue Shield denials.

When You're Eligible

You can request external review after receiving a "Final Adverse Benefit Determination" from your internal appeal. This applies to denials for:

  • Medical necessity
  • Experimental treatment determinations
  • Coverage disputes
  • Prior authorization rejections

How to File

Online: Visit pa.gov/reviewmyclaim Phone: 1-877-881-6388 Mail/Fax: Use forms from Pennsylvania Insurance Department website

What to Include

  • Final denial letter from Blue Cross Blue Shield
  • All medical records supporting the request
  • Treatment history and failed alternatives
  • Provider statements on medical necessity
  • Any additional evidence (within 15 days of IRO assignment)
Success Tip: The 50% overturn rate shows Pennsylvania's external reviewers frequently find in favor of patients. Don't be discouraged by an internal denial—external review offers genuine reconsideration.

Practical Scripts and Appeals Language

Patient Phone Script for Blue Cross Blue Shield

"Hello, I'm calling about a prior authorization denial for Natpara. I'd like to understand the specific clinical criteria your plan requires and request a peer-to-peer review with my physician. Can you also confirm the appeals deadline and provide the reference number for this denial? I'm in Pennsylvania, so I want to ensure I understand my state appeal rights."

Email Template for Medical Records

"Dear [Provider Office],

I need to appeal a Blue Cross Blue Shield denial for Natpara. Please provide:

  • Complete medical records showing hypoparathyroidism diagnosis
  • Lab results demonstrating inadequate calcium control on standard therapy
  • Documentation of symptoms and complications
  • Treatment history with dates and outcomes

I have a 180-day deadline for internal appeals. Thank you for your urgent assistance."

Appeal Letter Key Phrases

When citing state rules in your appeal:

  • "Under Pennsylvania's continuity of care protections..."
  • "Pennsylvania Insurance Code requires consideration of..."
  • "I request expedited review due to the urgent medical necessity..."
  • "This denial contradicts FDA-approved labeling which states..."

Limits and ERISA Plan Differences

Self-Funded Plan Limitations

If your employer's plan is self-funded (ERISA), some Pennsylvania protections may not apply:

  • External review rights may be limited
  • State insurance department cannot regulate the plan
  • Federal appeals process may apply instead

How to Check: Look for "self-funded" language on your insurance card or call HR to confirm.

Educational Considerations

Even ERISA plans often voluntarily follow state-like procedures. Many contract with Blue Cross Blue Shield for administration, meaning similar forms and timelines may apply even without legal requirements.

Quick Reference Resources

Pennsylvania Insurance Department

  • Consumer Services: 1-877-881-6388
  • External Review: pa.gov/reviewmyclaim
  • Complaint Filing: Pennsylvania Insurance Department website

Consumer Assistance Programs

  • Pennsylvania Health Law Project: Provides free legal assistance with appeals
  • Pennie Consumer Hotline: For marketplace plan issues
  • Office of Consumer Services: General insurance guidance

Blue Cross Blue Shield Plan Contacts

  • Highmark Blue Shield: Check member portal for current PA submission methods
  • Independence Blue Cross: Use provider portal for real-time coverage information

Note: Verify current contact information and submission methods, as these may change.

When to Escalate

Contact the Pennsylvania Insurance Department if:

  • Blue Cross Blue Shield misses deadlines
  • You're denied expedited review inappropriately
  • The plan doesn't follow state appeal procedures
  • You need help understanding your rights

What to Include in Complaints:

  • Policy number and member ID
  • Timeline of denials and appeals
  • Copies of all correspondence
  • Documentation of missed deadlines or procedural violations

FAQ

Q: How long does Blue Cross Blue Shield prior authorization take in Pennsylvania? A: Standard decisions: 15 days. Urgent decisions: 72 hours. Appeals: 30-60 days for internal, 45 days for external review.

Q: What if Natpara is non-formulary on my Blue Cross Blue Shield plan? A: You can request a formulary exception. Given Natpara's discontinuation, focus on medical necessity for alternative treatments and transition planning.

Q: Can I request an expedited appeal for Natpara? A: Yes, if delays could jeopardize your health. Hypocalcemia complications may qualify for urgent review (48-72 hour decisions).

Q: Does step therapy apply if I've failed treatments outside Pennsylvania? A: Yes, but you must provide documentation. Pennsylvania law requires insurers to consider all relevant medical history, regardless of where treatment occurred.

Q: What happens if Blue Cross Blue Shield denies my external review request? A: The Pennsylvania Insurance Department determines eligibility, not your insurer. Contact them directly if BCBS incorrectly states you're not eligible.

Q: Are there alternatives to Natpara that might be easier to get covered? A: Standard treatment remains calcium and vitamin D supplementation. Some clinicians consider teriparatide off-label, but coverage varies significantly.

Q: How much does Natpara cost without insurance? A: Takeda discontinued manufacturing, so no current list price exists. Focus appeals on transition planning and alternative treatment coverage.

Q: Can I get help with my appeal if I can't afford a lawyer? A: Yes. The Pennsylvania Health Law Project and other consumer assistance programs provide free help, especially for complex cases or low-income individuals.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform identifies denial reasons and drafts point-by-point rebuttals aligned to each plan's specific requirements, pulling the right medical citations and clinical documentation to strengthen your case.

For patients transitioning off Natpara, Counterforce Health can help navigate complex appeals for alternative treatments, ensuring your medical team has the tools needed to advocate effectively with Blue Cross Blue Shield and other insurers.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and state regulations can change. Always verify current requirements with your specific Blue Cross Blue Shield plan and consult healthcare providers for medical decisions. For legal assistance with complex appeals, consider contacting the Pennsylvania Health Law Project or other qualified advocates.

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