By Counterforce Health Team in Natpara (parathyroid hormone) —

How to Get Natpara (Parathyroid Hormone) Covered by Blue Cross Blue Shield in Virginia: Complete Requirements Guide and Appeals Process

Answer Box: Getting Natpara Covered by Blue Cross Blue Shield in Virginia

Natpara (parathyroid hormone) requires prior authorization from Blue Cross Blue Shield Virginia plans. However, Takeda discontinued global manufacturing in 2024, with U.S. supply ending December 31, 2025. New starts are typically denied due to lack of commercial availability.

For existing patients: Submit documentation through Anthem's Availity Essentials portal showing chronic hypoparathyroidism diagnosis, failed conventional therapy (calcium/vitamin D), and current lab values. If denied, Virginia's external review process provides a second chance within 120 days.

First step today: Contact your prescriber to confirm Natpara availability and discuss alternatives like optimized calcium/calcitriol therapy.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Natpara
  4. Coding and Billing Requirements
  5. Documentation Packet Checklist
  6. Submission Process
  7. Specialty Pharmacy Network
  8. After Submission: What to Expect
  9. Appeals Process in Virginia
  10. Common Pitfalls to Avoid
  11. Frequently Asked Questions

Who Should Use This Guide

This guide is for patients with chronic hypoparathyroidism and their healthcare providers seeking Natpara coverage through Blue Cross Blue Shield plans in Virginia. Given Takeda's manufacturing discontinuation, this primarily applies to:

  • Existing Natpara patients transitioning off therapy by end-2025
  • Patients exploring coverage options before considering alternatives
  • Clinicians documenting medical necessity for remaining supplies

Expected outcome: Most new start requests will be denied due to supply constraints. Focus should shift to optimizing conventional therapy or exploring off-label alternatives where clinically appropriate.

Member & Plan Basics

Coverage Requirements

  • Active BCBS Virginia coverage (primarily Anthem Blue Cross Blue Shield)
  • Prior authorization mandatory for all specialty biologics including Natpara
  • Specialty pharmacy dispensing required for coverage
  • Medical vs. pharmacy benefit: Self-administered = pharmacy benefit; provider-administered = medical benefit

Plan Types Affected

All Anthem BCBS Virginia plans require prior authorization for Natpara, including:

  • Commercial individual and group plans
  • Medicare Advantage plans
  • Some Medicaid managed care plans
Note: Verify your specific plan's requirements through the Anthem provider portal or member services.

Clinical Criteria for Natpara

FDA-Approved Indication

  • Chronic hypoparathyroidism in adults
  • Adjunct therapy with calcium and vitamin D
  • Not well-controlled on conventional therapy alone

Step Therapy Requirements

Before Natpara approval, patients must demonstrate:

  1. Confirmed diagnosis of chronic hypoparathyroidism with:
    • Serum PTH below normal on ≥2 occasions, 21+ days apart within past 12 months
    • Persistent hypocalcemia despite treatment
  2. Failed conventional therapy (≥12 weeks) with:
    • Maximal tolerated oral calcium supplements
    • Active vitamin D (calcitriol or alphacalcidol)
    • Adequate vitamin D stores (25-hydroxyvitamin D ≥20 ng/mL)
  3. Current lab requirements:
    • Serum calcium >7.5 mg/dL (to avoid severe hypocalcemia risk)
    • Normal magnesium levels
    • Age ≥18 years

Exclusions

  • Post-surgical hypoparathyroidism (temporary)
  • Calcium-sensing receptor mutations
  • Inadequate trial of conventional therapy

Coding and Billing Requirements

HCPCS Codes

  • Primary: J3590 (unclassified biologics)
  • Specify: "Natpara (parathyroid hormone, recombinant) for chronic hypoparathyroidism"

ICD-10 Diagnosis Codes

  • E20.9 - Hypoparathyroidism, unspecified
  • E20.0 - Idiopathic hypoparathyroidism
  • E83.51 - Hypocalcemia

Documentation Requirements

  • Complete diagnosis with ICD-10 codes
  • Prior therapy history with specific medications, doses, and duration
  • Current laboratory values (PTH, calcium, magnesium, vitamin D)
  • Prescriber specialty (endocrinology or nephrology preferred)

Documentation Packet Checklist

Provider Clinical Note Must Include:

  • Confirmed chronic hypoparathyroidism diagnosis
  • Duration of condition (≥6 months)
  • Prior treatment failures with specific details:
    • Calcium supplement types and doses
    • Active vitamin D preparations and doses
    • Treatment duration and patient response
  • Current symptoms and functional impact
  • Recent laboratory values (within 30 days)
  • Treatment goals and monitoring plan

Medical Necessity Letter Components:

  • Patient demographics and insurance information
  • Detailed medical history and diagnosis
  • Prior therapy trials with objective outcomes
  • Clinical rationale for Natpara therapy
  • Expected treatment duration and monitoring
  • Provider credentials and specialty

Required Attachments:

  • Recent laboratory reports
  • Prior therapy documentation
  • Hospital records (if applicable for hypocalcemic episodes)
  • Specialist consultation notes
Clinician Corner: Include FDA labeling references and endocrine society guidelines in your medical necessity letter. The Endocrine Society Clinical Practice Guideline provides evidence-based treatment recommendations that support advanced therapy when conventional treatment fails.

Submission Process

Anthem BCBS Virginia Submission Methods:

  1. Preferred: Availity Essentials portal (online tracking available)
  2. Alternative: Fax submission (verify current fax numbers through provider portal)
  3. Phone: Provider services for urgent cases

Required Forms:

  • Anthem specialty drug prior authorization form (download current version from provider portal)
  • Medical necessity letter
  • Supporting clinical documentation

Processing Timeline:

  • Standard review: 15 business days
  • Expedited review: 72 hours (for urgent medical necessity)

Specialty Pharmacy Network

In-Network Specialty Pharmacies in Virginia:

  • CVS Specialty (primary for medical benefit drugs)
  • BioPlus Specialty Pharmacy
  • CenterWell Pharmacy
  • Medical Park 11 Pharmacy
  • Noble Health Services Specialty Pharmacy
  • St. Matthews Specialty Pharmacy
  • Transcript Pharmacy
  • TwelveStone Health Partners
Important: Natpara must be dispensed through an in-network specialty pharmacy for coverage. Out-of-network use typically results in full denial.

Transfer Process:

  1. Confirm pharmacy participation in Anthem network
  2. Have prescriber send prescription directly to chosen pharmacy
  3. Pharmacy coordinates prior authorization if not already approved
  4. Verify shipping and storage requirements

After Submission: What to Expect

Confirmation Steps:

  • Record prior authorization reference number
  • Save submission confirmation (portal or fax receipt)
  • Set calendar reminder for follow-up (10 business days)

Status Monitoring:

  • Check Availity portal for real-time updates
  • Contact provider services if no response within stated timeframe
  • Document all communications with reference numbers

Approval Outcomes:

  • Full approval: Proceed to specialty pharmacy fulfillment
  • Partial approval: Review limitations and consider appeal if inadequate
  • Denial: Review reason codes and prepare appeal documentation

Appeals Process in Virginia

Given Natpara's limited availability, appeals focus on medical necessity for remaining supplies or coverage of alternatives.

Internal Appeal (Required First Step):

  • Timeline: 180 days from denial notice to file
  • Decision timeframe: 30 days standard, 72 hours expedited
  • Submit: Additional clinical documentation, peer-reviewed literature, specialist letters

Virginia External Review:

If internal appeal fails, Virginia offers independent review through the State Corporation Commission Bureau of Insurance.

Eligibility: Denials based on medical necessity or experimental/investigational classification

Process:

  1. Complete internal appeals first
  2. Submit Form 216-A within 120 days of final denial
  3. Include all clinical documentation and denial letters
  4. Decision timeline: 45 days standard, 72 hours expedited

Contact: Virginia Bureau of Insurance: 1-877-310-6560

The external review decision is binding on the insurer and provides an independent clinical assessment of your case.

Common Pitfalls to Avoid

Pitfall How to Prevent
Incomplete step therapy documentation Provide detailed records of calcium/vitamin D trials with doses, duration, and outcomes
Missing specialty prescriber Ensure endocrinologist or nephrologist involvement in care
Outdated lab values Submit labs within 30 days of request
Wrong pharmacy network Verify specialty pharmacy participation before prescription transfer
Missed deadlines Track all submission and appeal deadlines carefully

Frequently Asked Questions

Q: How long does BCBS Virginia prior authorization take for Natpara? A: Standard review takes 15 business days. Expedited review (72 hours) available for urgent medical necessity with physician certification.

Q: What if Natpara is not on my plan's formulary? A: Non-formulary drugs require formulary exception requests with enhanced medical necessity documentation. The process is similar but requires stronger clinical justification.

Q: Can I appeal if my request is denied due to supply constraints? A: Yes, but focus on alternatives. Appeals should emphasize medical necessity and explore coverage for alternative therapies like optimized conventional treatment or off-label options where appropriate.

Q: Does Virginia have special protections for rare disease medications? A: Virginia's external review process provides independent clinical assessment for all medical necessity denials, including rare disease treatments. The state's expedited review options ensure timely access to critical therapies.

Q: What documentation do I need for an appeal? A: Include the original denial letter, complete medical records, specialist consultation notes, relevant laboratory results, and any new clinical evidence supporting medical necessity.

Q: How can I get help with the appeals process? A: Contact Virginia's Bureau of Insurance Consumer Services at 1-877-310-6560 for guidance. The Virginia Poverty Law Center also provides assistance for complex insurance appeals.

Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed documentation that aligns with each payer's specific requirements. Our platform helps patients and providers navigate complex prior authorization processes and appeals, improving approval rates through systematic documentation and payer-specific workflows.

For patients facing Natpara denials or seeking coverage for alternative therapies, Counterforce Health can help develop comprehensive appeals that address Virginia-specific requirements and leverage the state's robust external review process to achieve coverage for medically necessary treatments.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and specific plan terms. Always consult with your healthcare provider and insurance plan directly for personalized guidance. Coverage policies and requirements may change; verify current information with official sources.

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