By Counterforce Health Team in Natpara (parathyroid hormone) —

How to Get Natpara (Parathyroid Hormone) Covered by Cigna in Washington: Complete 2025 Discontinuation Guide

Answer Box: Getting Natpara Covered by Cigna in Washington

Critical Update: Natpara was discontinued by Takeda on December 31, 2024. Existing patients have access through the Special Use Program until December 31, 2025, but new prescriptions are generally denied due to lack of commercial supply.

For current patients: Submit prior authorization through EviCore by Evernorth with documented failure of maximum calcium/vitamin D therapy. If denied, use Washington's strong external review process through Independent Review Organizations (IROs) - decisions overturn ~82% of specialty drug denials. Contact the Washington Insurance Commissioner at 1-800-562-6900 for help navigating appeals.

First step today: Gather your latest PTH and calcium lab results, document all prior calcium/vitamin D trials, and work with your endocrinologist to submit a comprehensive medical necessity letter.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding and Documentation
  5. The Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Routing
  8. After Submission: What to Expect
  9. Appeals Process in Washington
  10. Common Denial Reasons & Solutions
  11. Costs and Patient Support
  12. FAQ

Who Should Use This Guide

This guide is designed for:

  • Current Natpara patients transitioning from the Special Use Program before December 31, 2025
  • Endocrinologists and nephrologists managing hypoparathyroidism patients on Cigna plans
  • Patients with chronic hypoparathyroidism who've failed conventional calcium and vitamin D therapy
  • Caregivers navigating insurance coverage for rare disease treatments

Expected outcome: While new Natpara prescriptions face automatic denial due to discontinuation, existing patients may secure continued coverage through 2025 with proper documentation. This guide provides the exact requirements and appeal strategies specific to Cigna and Washington state law.

Member & Plan Basics

Coverage Requirements

  • Active Cigna coverage (commercial, Medicare Advantage, or Medicaid managed care)
  • Specialty pharmacy benefits through Express Scripts/Accredo
  • Prior authorization mandatory - no exceptions for any plan type

Plan Type Considerations

Plan Type Key Details Authorization Portal
Commercial PPO/HMO Standard PA through EviCore EviCore portal
Medicare Advantage Enhanced appeals rights Same portal + CMS options
Medicaid Managed State-specific requirements Provider portal + phone
Note: Self-funded employer plans may have different appeal rights - verify ERISA vs. state law protections with your HR department.

Clinical Criteria Requirements

Primary Indication

Cigna's coverage policy requires:

  • Chronic hypoparathyroidism diagnosed ≥6 months
  • Inadequate control on maximum tolerated calcium supplements plus active vitamin D
  • Serum calcium >7.5 mg/dL before initiating therapy
  • Sufficient 25-hydroxyvitamin D stores documented

Step Therapy Requirements

You must demonstrate documented failure of:

  1. Calcium supplementation (maximum tolerated dose for ≥12 weeks)
  2. Active vitamin D (calcitriol or equivalent for ≥12 weeks)
  3. Combined therapy with specific doses and duration

Laboratory Thresholds

  • PTH levels: Below normal range on ≥2 occasions, 21+ days apart
  • Serum calcium: Persistent hypocalcemia despite treatment
  • Recent labs: All values within 30 days of submission

Coding and Documentation

ICD-10 Codes

  • E20.0 - Idiopathic hypoparathyroidism (primary)
  • E20.9 - Hypoparathyroidism, unspecified
  • E83.51 - Hypocalcemia (concurrent diagnosis)

HCPCS Coding

  • J3590 - Natpara (parathyroid hormone, recombinant)
  • Specify "for chronic hypoparathyroidism" in claims

Units and Billing

  • Bill per actual dose administered
  • Include NDC number on all claims
  • Document injection site and administration method

The Documentation Packet

Core Medical Necessity Letter Components

Your endocrinologist's letter must include:

Clinical History

  • Diagnosis date and etiology of hypoparathyroidism
  • Symptom severity and impact on daily functioning
  • Previous hospitalizations for hypocalcemia

Treatment Timeline

  • Complete list of calcium preparations tried (type, dose, duration)
  • Vitamin D analogs used (calcitriol, ergocalciferol, doses, timeline)
  • Documented treatment failures with specific outcomes
  • Adverse effects or contraindications to alternatives

Current Status

  • Recent laboratory values (PTH, calcium, phosphorus, magnesium, vitamin D)
  • Current symptom assessment
  • Quality of life impact documentation

Clinical Rationale

  • Why conventional therapy is inadequate
  • Treatment goals with Natpara
  • Monitoring plan and safety considerations

Required Attachments Checklist

  • Complete laboratory reports (last 6 months)
  • Prior therapy documentation with dates and outcomes
  • Hospital records for hypocalcemic episodes (if applicable)
  • Current medication list with doses
  • Specialist consultation notes
  • Patient insurance card copy
  • Completed prior authorization form (current version)

Submission Process

Primary Submission Method

Submit through EviCore by Evernorth:

  1. Log into provider portal
  2. Select "Pharmacy Prior Authorization"
  3. Complete Natpara-specific form
  4. Upload all supporting documents
  5. Submit and record confirmation number

Alternative Methods

  • Phone: 1-800-882-4462 (if electronic submission fails)
  • Fax: Use number provided in portal (verify current)

Required Form Fields That Commonly Cause Rejections

  • Patient's exact name as it appears on insurance card
  • Complete diagnosis with ICD-10 codes
  • Prescriber NPI number
  • Specific medication strength and dosing schedule
  • Prior therapy section completely filled out
  • Clinical rationale section with specific details

Specialty Pharmacy Routing

Accredo Specialty Pharmacy

Once approved, Natpara is dispensed through Accredo:

Setup Process

  1. Cigna forwards approved PA to Accredo
  2. Accredo contacts patient within 24-48 hours
  3. Patient completes enrollment and shipping preferences
  4. First shipment typically within 3-5 business days

Transfer from Current Pharmacy

  • Accredo handles prescription transfer
  • Provide current pharmacy information
  • Verify no gaps in therapy during transition

Shipment Verification

  • Track shipments through Accredo portal
  • Verify cold-chain integrity upon receipt
  • Report any shipping issues immediately

After Submission: What to Expect

Timeline for Decisions

  • Standard review: 72 hours (auto-approved if no response)
  • Complex cases: Up to 15 business days
  • Expedited review: 24 hours (for urgent medical necessity)

Status Checking

  • Check EviCore portal for real-time updates
  • Record all confirmation numbers
  • Document all phone conversations with dates/times

What to Record

  • Prior authorization reference number
  • Submission date and method
  • Follow-up call dates and outcomes
  • Any additional information requests

Appeals Process in Washington

Washington residents have exceptionally strong appeal rights for specialty drug denials.

Internal Appeals (Required First)

Level 1 Internal Appeal

  • Timeline: File within 180 days of denial
  • Decision: Within 30 days (72 hours if expedited)
  • Submit to: Cigna Appeals Department

Level 2 Internal Appeal

  • Timeline: Within 180 days of Level 1 denial
  • Decision: Within 30 days
  • Enhanced review: Often involves clinical specialists

External Review Through IRO

When Available: After completing internal appeals or if Cigna fails to respond timely

Success Rate: Approximately 82% of specialty drug denials are overturned in Washington external review

How to Request:

  1. Contact Washington Insurance Commissioner at 1-800-562-6900
  2. Submit request within 180 days of final internal denial
  3. Commissioner assigns certified IRO within 5 business days
  4. IRO decision within 30 days (72 hours if expedited)

Cost: Free to patients - Cigna pays all IRO costs

Binding Decision: IRO decisions are binding on Cigna and must be implemented immediately if overturned

For patients navigating complex appeals, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to the plan's own rules.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Provide detailed symptom documentation and quality of life impact Specialist letter, hospital records, functional assessments
"Step therapy not completed" Document specific trials, doses, duration, and failures Pharmacy records, clinic notes with dates and outcomes
"Experimental/investigational" Cite FDA approval and clinical guidelines FDA label, endocrine society guidelines, peer-reviewed studies
"Non-formulary" Request formulary exception with medical necessity Comparative effectiveness data, contraindications to alternatives
"Quantity limits exceeded" Justify dosing based on patient-specific factors Weight-based calculations, dose titration records

Costs and Patient Support

Manufacturer Support

  • Takeda Patient Support: Limited due to discontinuation
  • Special Use Program: Access through December 31, 2025 only

Alternative Financial Assistance

  • State pharmaceutical assistance programs: Check Washington state options
  • Rare disease foundations: Patient Advocate Foundation, others
  • Hospital charity care: For hypocalcemia-related admissions

Transition Planning

Given Natpara's discontinuation, work with your endocrinologist now to:

  • Optimize calcium and vitamin D regimens
  • Consider off-label alternatives like teriparatide (if appropriate)
  • Plan for enhanced monitoring during transition

FAQ

How long does Cigna prior authorization take in Washington? Standard review is 72 hours, with auto-approval if Cigna doesn't respond. Complex cases may take up to 15 business days. Expedited review for urgent cases is 24 hours.

What if Natpara is non-formulary on my Cigna plan? Request a formulary exception through the prior authorization process. Include medical necessity documentation and evidence that formulary alternatives are inappropriate or contraindicated.

Can I request an expedited appeal in Washington? Yes. If your health could be in serious jeopardy, request expedited review at both internal appeal and external IRO levels. Decisions come within 72 hours for internal appeals and 72 hours for IRO review.

Does step therapy apply if I failed treatments outside Washington? Yes, but ensure your documentation clearly shows the trials, failures, and dates. Out-of-state treatment records are acceptable if properly documented.

What happens after December 31, 2025? Natpara will no longer be available. Work with your endocrinologist now to optimize alternative treatments and develop a comprehensive transition plan.

How do I contact the Washington Insurance Commissioner for help? Call 1-800-562-6900 for the Consumer Advocacy line. They can help with appeals, provide template letters, and guide you through the external review process.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and work with qualified professionals for insurance appeals. Coverage policies and state regulations may change - verify current requirements with official sources.

For comprehensive assistance with insurance appeals and coverage denials, Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals that meet payer-specific requirements and procedural deadlines.

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