By Counterforce Health Team in Nourianz (istradefylline) —

How to Get Nourianz (Istradefylline) Approved by Aetna CVS Health in Pennsylvania: Step-by-Step Prior Authorization Guide

Answer Box: Getting Nourianz (Istradefylline) Approved by Aetna CVS Health in Pennsylvania

Aetna CVS Health requires prior authorization for Nourianz (istradefylline) with step therapy requirements in Pennsylvania. You'll need documented failure of amantadine, MAO-B inhibitors (like rasagiline), or COMT inhibitors (like entacapone), plus proof of 3+ hours daily "off" episodes via patient diary. Submit the CVS Caremark Formulary Exception/PA Form via ePA or fax to 1-888-267-3277. Standard decisions take ≤72 hours; expedited ≤24 hours. If denied, Pennsylvania's new Independent External Review program overturns 50% of appeals within 45 days.

First step today: Verify your Aetna plan covers specialty drugs and gather your Parkinson's diagnosis records, medication history, and recent neurologist notes.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Plan Verification
  3. Gather What You Need
  4. Submit the Prior Authorization Request
  5. Follow-Up and Tracking
  6. Typical Timelines
  7. If You're Asked for More Information
  8. If Denied: Appeals Process
  9. Pennsylvania's External Review Advantage
  10. Renewal and Re-Authorization
  11. Quick Reference Checklist
  12. FAQ

What This Guide Covers

This comprehensive guide helps Parkinson's disease patients and their healthcare providers navigate Aetna CVS Health's prior authorization process for Nourianz (istradefylline) in Pennsylvania. Whether you're dealing with an initial request, denial, or appeal, we'll walk you through each step with current forms, deadlines, and Pennsylvania-specific advantages.

Nourianz is an oral adenosine A2A receptor antagonist that helps reduce "off" episodes when taken alongside carbidopa/levodopa. At approximately $1,900-$2,100 per month, prior authorization is typically required by most insurance plans, including Aetna CVS Health.

Before You Start: Plan Verification

Confirm Your Coverage Type

Not all Aetna plans are the same. Check if you have:

  • Commercial Aetna plan (individual or employer-sponsored)
  • Aetna Medicare Advantage
  • Aetna Better Health (Pennsylvania Medicaid)
Note: Self-funded employer plans may have different rules. Contact your HR department to confirm if your plan is self-funded, as this affects your appeal rights in Pennsylvania.

Check Nourianz's Formulary Status

Log into your Aetna member portal or review your 2025 drug guide to confirm:

  • Prior Authorization (PA) required: Yes for most Aetna plans
  • Step Therapy (ST) applies: Typically yes
  • Formulary tier: Usually non-preferred or specialty tier

Gather What You Need

Essential Documentation Checklist

Medical Records:

  • Parkinson's disease diagnosis with ICD-10 code G20
  • Recent neurologist consultation notes (within 3-6 months)
  • Complete medication history showing prior therapy trials
  • Patient diary documenting ≥3 hours daily "off" episodes (minimum 3 days)

Insurance Information:

  • Aetna member ID and policy details
  • Current prescription benefits summary
  • Any previous denial letters (if resubmitting)

Step Therapy Documentation Requirements

Aetna typically requires documented failure of medications from these classes:

Drug Class Examples Documentation Needed
Immediate/Extended-Release Amantadine Amantadine HCL 100mg Trial dates, dosage, reason for discontinuation
MAO-B Inhibitors Rasagiline, selegiline, safinamide Inadequate response or intolerance details
COMT Inhibitors Entacapone, tolcapone, opicapone Clinical notes showing failure/side effects

OFF Episode Documentation

Your neurologist needs evidence of significant "off" time. The gold standard is a patient diary tracking:

  • Duration: Total hours per day of "off" episodes
  • Timing: Relationship to levodopa doses
  • Symptoms: Tremor, stiffness, mobility issues, anxiety
  • Impact: Functional limitations during episodes

Counterforce Health helps patients and providers compile this documentation into targeted, evidence-backed appeals that address payer-specific requirements.

Submit the Prior Authorization Request

Fastest Submission Methods

Electronic Prior Authorization (ePA):

  • Submit via Availity portal for fastest processing
  • Most efficient for routine requests

Fax Submission:

  • Specialty drugs fax: 1-888-267-3277
  • Medicare Part D: 1-855-344-0930 or 1-855-633-7673
  • Include cover sheet with member ID and prescriber information

Forms to Use:

Clean Request Packet Checklist

✓ Completed PA form with all required fields
✓ Prescriber attestation and signature
✓ Patient diary showing ≥3 hours daily off time
✓ Documentation of step therapy failures
✓ Recent neurologist notes supporting medical necessity
✓ Prescription for Nourianz with clear dosing instructions

Follow-Up and Tracking

When to Call Aetna CVS Health

Standard timeline: Contact if no response within 72 hours
Expedited requests: Follow up within 24 hours if urgent

Phone numbers:

  • CVS Caremark PA Department: Available Monday-Friday, 8AM-6PM CST
  • Member Services: Number on back of your Aetna ID card

Sample Call Script

"Hi, I'm calling to check the status of a prior authorization request for Nourianz (istradefylline) for [patient name], member ID [number]. The request was submitted on [date] via [method]. Can you provide the current status and expected decision timeline?"

Document: Reference number, representative name, and next steps.

Typical Timelines

Pennsylvania-Specific Requirements

Request Type Aetna Decision Timeline Pennsylvania Rights
Standard PA ≤72 hours Internal appeal: 180 days from denial
Expedited PA ≤24 hours (urgent medical need) External review: 4 months from final denial
Appeal Decision ≤30-45 days External review decision: 45 days (standard)

What Speeds Decisions

  • Complete documentation on first submission
  • Electronic submission via ePA
  • Clear medical necessity rationale
  • Proper step therapy documentation

What Slows Decisions

  • Missing clinical notes
  • Incomplete step therapy documentation
  • Unclear off-episode quantification
  • Wrong forms or submission method

If You're Asked for More Information

Common Medical Necessity Questions

"Please provide evidence of inadequate response to previous therapies"

  • Submit clinic notes with specific details: dosage tried, duration of trial, reason for discontinuation
  • Include patient-reported outcomes during each trial

"Documentation of off episodes insufficient"

  • Provide detailed patient diary with timestamps
  • Include caregiver observations if available
  • Submit validated Parkinson's assessment scores if available

Literature Support

Include these evidence sources when strengthening your case:

If Denied: Appeals Process

Common Denial Reasons and Solutions

Denial Reason Solution Strategy
Step therapy not met Provide detailed documentation of prior therapy failures with dates and clinical rationale
Non-formulary status Request formulary exception with medical necessity letter
Insufficient off-episode documentation Submit comprehensive patient diary and neurologist assessment
Missing concurrent levodopa Confirm current levodopa prescription and dosing schedule

Internal Appeal Process

Timeline: Submit within 180 days of denial letter
Required documents:

  • Original denial letter
  • Neurologist's medical necessity letter
  • Updated clinical documentation
  • Patient diary and functional impact assessment

Submission: Use same channels as original PA request

Peer-to-Peer Review

Request a peer-to-peer review where your neurologist speaks directly with Aetna's medical director:

  • Often resolves complex cases quickly
  • Allows real-time clarification of clinical rationale
  • Can be requested during initial PA or appeal process

Pennsylvania's External Review Advantage

New State Program Success Rate

Pennsylvania launched its Independent External Review Program in January 2024, with impressive results:

  • 50.1% success rate in first year (259 of 517 cases overturned)
  • 45-day standard timeline for decisions
  • 72-hour expedited review for urgent cases

How It Works

  1. Complete Aetna's internal appeal and receive Final Adverse Benefit Determination
  2. Submit external review request within 4 months at pa.gov/reviewmyclaim
  3. Independent review organization (IRO) evaluates your case
  4. Decision is binding - if overturned, Aetna must provide coverage

Eligibility Requirements

  • Commercial health plans (not self-funded employer plans)
  • Must exhaust Aetna's internal appeals process first
  • Applies to medical necessity denials, experimental treatment claims, and coverage disputes
From our advocates: We've seen Pennsylvania's external review program particularly effective for specialty neurological medications like Nourianz. The independent physicians reviewing these cases often have deeper expertise in movement disorders than insurance company reviewers, leading to more informed decisions about medical necessity.

Renewal and Re-Authorization

When to Start the Process

  • Calendar reminder: Set for 30 days before current authorization expires
  • Typical authorization period: 6-12 months for Nourianz
  • Documentation needed: Updated clinical notes showing continued benefit and medical necessity

Streamlined Renewal Strategy

If Nourianz has been effective:

  • Document functional improvements during treatment
  • Note any reduction in off-episode frequency or duration
  • Include updated patient diary showing sustained benefit
  • Emphasize continued medical necessity for ongoing therapy

Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed submissions that align with each payer's specific requirements and timelines.

Quick Reference Checklist

Before submitting: □ Verify Aetna plan type and Nourianz formulary status
□ Gather PD diagnosis, medication history, and neurologist notes
□ Complete 3+ day off-episode diary
□ Document step therapy failures with dates and outcomes

Submission: □ Use CVS Caremark PA form via ePA or fax to 1-888-267-3277
□ Include all required clinical documentation
□ Note reference number and submission date

Follow-up: □ Track status within 72 hours (24 hours for expedited)
□ Prepare appeal documents if denied
□ Consider Pennsylvania external review if internal appeals fail

Pennsylvania advantage: □ Use state external review program within 4 months of final denial
□ Submit at pa.gov/reviewmyclaim
□ 50% success rate with binding decisions

FAQ

How long does Aetna CVS Health prior authorization take in Pennsylvania? Standard PA decisions are made within 72 hours, expedited requests within 24 hours. Pennsylvania doesn't have specific PA timelines that differ from federal requirements.

What if Nourianz is non-formulary on my Aetna plan? Request a formulary exception by demonstrating medical necessity and documenting failure of formulary alternatives. Include a detailed neurologist letter explaining why formulary options are inappropriate.

Can I request an expedited appeal in Pennsylvania? Yes, expedited appeals are available for urgent medical situations where a 30-60 day delay could worsen your condition. Both Aetna and Pennsylvania's external review program offer expedited timelines.

Does step therapy apply if I failed medications outside Pennsylvania? Yes, documented medication failures from any location count toward step therapy requirements. Provide complete medical records showing trial dates, dosages, and reasons for discontinuation.

What's the cost difference between paying cash and using insurance? Nourianz costs approximately $1,900-$2,100 per month without insurance. With Aetna coverage, your cost depends on your plan's specialty drug copay or coinsurance structure.

How do I find help with the appeals process in Pennsylvania? Contact the Pennsylvania Insurance Department's Office of Consumer Services at 1-877-881-6388, or use the Pennsylvania Health Law Project for free assistance with complex appeals.

Sources & Further Reading

Disclaimer: This guide is for informational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan terms and clinical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For questions about Pennsylvania insurance regulations, contact the Pennsylvania Insurance Department at 1-877-881-6388.

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