By Counterforce Health Team in Natpara (parathyroid hormone) —

How to Get Natpara (Parathyroid Hormone) Covered by Cigna in Pennsylvania: Complete Requirements Guide

Answer Box: Getting Natpara Covered by Cigna in Pennsylvania

Who's eligible: Adults with chronic hypoparathyroidism who've failed maximized calcium and vitamin D therapy, with documented low PTH levels on two separate tests.

Fastest path to approval:

  1. Submit prior authorization through CignaforHCP.com with complete lab documentation
  2. Complete REMS enrollment via the NATPARA REMS Program
  3. Route prescription through Accredo specialty pharmacy (877-826-7657)

First step today: Verify your Cigna plan type (fully insured vs. self-funded) and gather your most recent PTH and calcium lab results from the past 12 months.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Documentation Packet
  5. Submission Process
  6. Specialty Pharmacy Routing
  7. After Submission
  8. Common Denial Prevention Tips
  9. Appeals Process in Pennsylvania
  10. FAQ

Who Should Use This Guide

This comprehensive guide is designed for patients and healthcare providers navigating Cigna's prior authorization process for Natpara (parathyroid hormone) in Pennsylvania. You should use this guide if:

  • You have chronic hypoparathyroidism that's inadequately controlled with standard therapy
  • Your endocrinologist has recommended Natpara as adjunct treatment
  • You have Cigna insurance coverage in Pennsylvania
  • You've received a denial and need to understand the appeals process

Expected outcome: With proper documentation and submission, approval rates for medically necessary Natpara requests are significantly higher when all clinical criteria are met and properly documented.

Important: Natpara manufacturing ceased in December 2024, with the FDA Special Use Program ending December 31, 2025. New patients should discuss alternative treatments like Yorvipath (palopegteriparatide) with their endocrinologist.

Member & Plan Basics

Verify Active Coverage

Before starting the authorization process:

  • Check your Cigna ID card for current coverage dates
  • Confirm plan type: Call the number on your card to verify if you have a fully insured plan (eligible for Pennsylvania external review) or self-funded/ERISA plan
  • Specialty pharmacy benefits: Most Cigna plans require specialty medications through Accredo

Deductible and Authorization Requirements

Natpara is subject to:

  • Prior authorization (PA) requirement on all Cigna plans
  • Specialty tier copayment structure
  • Quantity limits based on FDA-approved dosing
  • Step therapy requirements (must try/fail conventional therapy first)

Clinical Criteria Requirements

FDA-Approved Indication

Natpara is only covered for adults with chronic hypoparathyroidism as adjunct to calcium and vitamin D therapy. Cigna's coverage policy requires all of the following:

Laboratory Requirements

Lab Test Requirement Timing
Serum PTH Below lower limit of normal Two tests ≥21 days apart within past 12 months
Serum Calcium Documented hypocalcemia, but >7.5 mg/dL before starting Recent results required
25-OH Vitamin D Sufficient levels (>50 nmol/L) Before initiation
Serum Magnesium Within normal range Before initiation

Step Therapy Documentation

You must document failure, intolerance, or contraindication to maximized conventional therapy:

  • Oral calcium supplements: ≥1000 mg elemental calcium daily
  • Active vitamin D: Calcitriol ≥0.25 mcg/day or alfacalcidol ≥0.5 mcg/day
  • Evidence of inadequate control: Persistent hypocalcemia, hypercalciuria, nephrolithiasis, or inability to maintain safe calcium levels

Prescriber Requirements

  • Must be prescribed by or in consultation with an endocrinologist or nephrologist
  • Prescriber must be enrolled in the NATPARA REMS program

Documentation Packet

Provider Note Elements

Your endocrinologist's note should include:

Diagnosis Documentation:

  • ICD-10 code (E20.0 for idiopathic, E20.8 for other, E20.9 for unspecified hypoparathyroidism)
  • Etiology and duration of condition
  • Current symptoms and functional impact

Laboratory Evidence:

  • All required lab values with reference ranges and dates
  • Trend showing persistent hypocalcemia despite treatment
  • Documentation of calcium >7.5 mg/dL immediately before starting Natpara

Treatment History:

  • Detailed record of calcium and vitamin D doses tried
  • Duration of each treatment attempt
  • Specific reasons for failure (persistent symptoms, side effects, safety concerns)
  • Any contraindications to increasing conventional therapy

Medical Necessity Letter Components

Include these key elements in your letter of medical necessity:

  1. Patient-specific rationale for why Natpara is medically necessary
  2. Clinical guidelines support referencing FDA labeling and endocrine society recommendations
  3. Treatment goals and monitoring plan
  4. Risk-benefit analysis comparing continued conventional therapy vs. Natpara

Required Attachments

  • Recent office visit notes (past 3-6 months)
  • Complete laboratory results showing PTH and calcium trends
  • Documentation of prior therapy trials and outcomes
  • REMS Patient-Prescriber Acknowledgment Form (completed and signed)

Submission Process

Electronic Prior Authorization

Primary submission method: CignaforHCP.com

  1. Log into provider portal
  2. Select "Pharmacy Prior Authorization"
  3. Choose "Pharmacy Drugs (Express Scripts Coverage)"
  4. Complete Natpara-specific form with all required fields
  5. Upload supporting documentation

Alternative Submission Methods

If electronic submission isn't available:

  • Phone: 1-800-882-4462 for medication precertification
  • Fax: Use number provided in portal or PA form (verify current number)

Required Fields That Commonly Cause Rejections

  • Incomplete lab data: Missing dates or reference ranges
  • Insufficient prior therapy documentation: Vague descriptions of "failed" treatments
  • Missing prescriber specialty: Not clearly identified as endocrinologist/nephrologist
  • Incorrect dosing: Not aligned with FDA-approved starting doses

Specialty Pharmacy Routing

Accredo Enrollment Process

Once PA is approved, Cigna typically requires Natpara to be filled through Accredo specialty pharmacy:

  1. Call Accredo: 877-826-7657 to initiate enrollment
  2. Prescription transfer: Accredo can transfer existing prescriptions from other pharmacies
  3. Patient onboarding: Accredo contacts patient within 24-48 hours for enrollment
  4. Shipping coordination: Initial shipment typically 3-5 business days after enrollment

REMS Program Requirements

Both patient and prescriber must complete REMS enrollment:

  • Patient counseling on benefits and risks
  • Signed acknowledgment form submitted to REMS Coordinating Center
  • REMS hotline: 1-844-NAT-REMS for questions

After Submission

Tracking Your Request

  • Record confirmation number from submission
  • Standard review timeline: 72 hours for non-urgent requests
  • Complex cases: Up to 15 business days
  • Expedited review: 24 hours for urgent medical situations

Status Monitoring

Check status via:

  • Cigna provider portal
  • Phone follow-up using confirmation number
  • Accredo coordination once approved

Documentation to Maintain

Keep records of:

  • Submission dates and confirmation numbers
  • All correspondence with Cigna
  • REMS enrollment confirmation
  • Accredo enrollment details

Common Denial Prevention Tips

Five Pitfalls and How to Avoid Them

  1. Insufficient lab documentation
    • Fix: Include complete lab panels with dates, values, and reference ranges for all required tests
  2. Vague prior therapy history
    • Fix: Provide specific doses, duration, and objective outcomes for each treatment trial
  3. Missing REMS enrollment
    • Fix: Complete REMS process before or concurrent with PA submission
  4. Non-specialist prescriber
    • Fix: Ensure endocrinologist or nephrologist is clearly identified as prescriber
  5. Inadequate medical necessity rationale
    • Fix: Connect clinical presentation to specific Cigna coverage criteria with supporting guidelines

Appeals Process in Pennsylvania

If your Natpara request is denied, Pennsylvania residents have robust appeal rights:

Internal Appeals with Cigna

  • First-level internal appeal: File within 180 days of denial
  • Required documentation: Additional clinical evidence, peer-reviewed studies, treatment guidelines
  • Timeline: Cigna must respond within specified timeframes per your plan documents

Pennsylvania External Review

For fully insured Cigna plans, you can access Pennsylvania's Independent External Review program:

  • Eligibility: Must complete Cigna's internal appeal first
  • Deadline: 4 months from Final Adverse Benefit Determination letter
  • Success rate: Approximately 50% of external reviews overturn initial denials
  • Cost: No fee to patients
  • Timeline: 45 days for standard review, 72 hours for expedited

When to Request Expedited Review

Request expedited processing if:

  • Delay would seriously jeopardize your health
  • You're experiencing frequent hypocalcemic episodes
  • Current therapy is causing significant complications
From our advocates: We've seen cases where detailed documentation of hypocalcemic episodes requiring emergency care significantly strengthened appeals. Include ER records and frequency data when available – this objective evidence often resonates with medical reviewers.

FAQ

Q: How long does Cigna prior authorization take for Natpara in Pennsylvania? A: Standard reviews take about 72 hours, with complex cases up to 15 business days. Expedited reviews for urgent situations are completed within 24 hours.

Q: What if Natpara is non-formulary on my Cigna plan? A: You can request a formulary exception by demonstrating medical necessity and failure of formulary alternatives. The same clinical documentation applies.

Q: Can I request an expedited appeal if denied? A: Yes, if delay would jeopardize your health. Document the urgency with clinical evidence and request expedited processing at each level.

Q: Does Pennsylvania's external review apply to all Cigna plans? A: Only fully insured commercial plans regulated by Pennsylvania. Self-funded/ERISA employer plans follow federal appeal procedures.

Q: What happens after Natpara is discontinued in 2025? A: Discuss alternatives like Yorvipath with your endocrinologist. The same PA principles apply to alternative PTH therapies.

Q: How do I transfer my prescription to Accredo? A: Call Accredo at 877-826-7657 with your current pharmacy information, or ask your prescriber to send a new prescription directly to Accredo.

Counterforce Health: Streamlining Your Appeal Process

Counterforce Health specializes in turning insurance denials into successful appeals for specialty medications like Natpara. Our platform analyzes your specific denial reason and generates evidence-backed appeals tailored to your payer's own coverage policies. We help patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements by identifying the exact clinical criteria and documentation needed for approval.

For Pennsylvania residents facing Cigna denials, our system can help prepare comprehensive appeals that address medical necessity requirements, compile appropriate clinical evidence, and meet all procedural deadlines – including Pennsylvania's external review process.

Sources & Further Reading

Disclaimer: This guide provides educational information about insurance coverage processes and should not be considered medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance company directly for coverage determinations. Coverage policies and procedures may change; verify current requirements with your specific plan. For additional help with Pennsylvania insurance issues, contact the Pennsylvania Insurance Department at 1-877-881-6388.

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