By Counterforce Health Team in Nourianz (istradefylline) —

How to Get Nourianz (Istradefylline) Covered by Cigna in Ohio: Complete Prior Authorization and Appeals Guide

Answer Box: To get Nourianz (istradefylline) covered by Cigna in Ohio, you need prior authorization with documented Parkinson's disease, current carbidopa/levodopa use, and failed trials of amantadine, MAO-B inhibitors, and COMT inhibitors. Submit through your neurologist with OFF episode documentation. If denied, you have 180 days for internal appeals, then external review through Ohio Department of Insurance. Start today: Contact your neurologist to gather step therapy documentation and schedule a visit to document OFF episodes.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Patient Profile: Who Qualifies
  3. Pre-Authorization Preparation
  4. Submission Process
  5. Common Denial Reasons & Solutions
  6. Appeals Process in Ohio
  7. Cost and Savings Options
  8. When to Escalate
  9. FAQ

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed
Prior Authorization Required for all Nourianz prescriptions Completed PA form via provider portal
Formulary Status Tier 4 specialty drug Dispensed through Accredo specialty pharmacy
Prescriber Must be neurologist or in consultation with one Provider credentials verification
Step Therapy Failed amantadine, MAO-B, and COMT inhibitors Medication history with dates/outcomes
Current Therapy Active carbidopa/levodopa prescription Recent prescription records
OFF Episodes Documented motor fluctuations ≥3 hours/day Patient diary and clinical notes
Quantity Limit 30-day supply maximum Standard dispensing quantity

Source: Cigna Coverage Policy

Patient Profile: Who Qualifies

Sarah, 64, from Columbus represents a typical Nourianz candidate. Diagnosed with Parkinson's disease three years ago, she's been on carbidopa/levodopa 25/100 mg three times daily but still experiences 4-5 hours of OFF time daily—periods when her medication wears off and symptoms return.

Her neurologist documented failed trials of:

  • Amantadine (discontinued due to ankle swelling)
  • Rasagiline (MAO-B inhibitor, caused insomnia)
  • Entacapone (COMT inhibitor, led to severe nausea)

Sarah keeps a daily diary showing OFF episodes interfering with work and daily activities. Her case demonstrates the typical approval pathway: established diagnosis, optimized levodopa therapy, documented step therapy failures, and persistent functional impairment.

Pre-Authorization Preparation

Step 1: Gather Required Documentation

Medical Records Needed:

  • Parkinson's disease diagnosis (ICD-10: G20)
  • Current carbidopa/levodopa prescription with dosing
  • Documentation of failed step therapy medications
  • OFF episode diary (minimum 2 weeks recommended)
  • Neurologist consultation notes

Step Therapy Documentation Must Include:

  • Amantadine: Both immediate and extended-release trials
  • MAO-B inhibitor: Rasagiline, safinamide, or selegiline
  • COMT inhibitor: Entacapone, opicapone, or tolcapone
  • Specific reasons for discontinuation (ineffective, adverse effects, contraindications)

Step 2: Document OFF Episodes

Create a detailed diary tracking:

  • Time of day symptoms worsen
  • Duration of OFF periods
  • Specific symptoms (stiffness, slowness, tremor)
  • Impact on daily activities
  • Relationship to medication timing
Tip: Most insurance reviewers look for ≥3 hours of daily OFF time despite optimized levodopa therapy.

Submission Process

Step-by-Step: Fastest Path to Approval

  1. Neurologist Initiates PA (Timeline: Same day)
    • Access Cigna provider portal or call 1-800-88-CIGNA
    • Complete prior authorization request form
    • Upload all supporting documentation
  2. Submit Complete Package (Timeline: 1-2 business days)
    • PA form with clinical rationale
    • Step therapy failure documentation
    • OFF episode diary and clinical notes
    • Current medication list
  3. Cigna Review Process (Timeline: 72 hours standard, 24 hours expedited)
    • Medical necessity review
    • Step therapy verification
    • Formulary status confirmation
  4. Receive Decision (Timeline: Within review period)
    • Approval: Coverage activated in pharmacy system
    • Denial: Written explanation with appeal rights

Required Forms and Portals

For Providers:

For Patients:

  • Cigna member portal for status tracking
  • Phone support: 1-800-88-CIGNA

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Evidence
Insufficient step therapy Document all required medication trials Pharmacy records, provider notes with dates
Missing OFF episode documentation Submit detailed symptom diary 2+ week patient diary, clinical assessment
No neurologist involvement Ensure specialist consultation Referral documentation, specialist notes
Quantity limit exceeded Request standard 30-day supply Adjust prescription quantity
Not medically necessary Provide clinical justification Guidelines, peer-reviewed evidence

Appeals Process in Ohio

Internal Appeals with Cigna

First Level Appeal:

  • Deadline: 180 days from denial date
  • Process: Written request with additional clinical evidence
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Contact: Submit via member portal or mail to address on denial letter

Second Level Appeal:

  • Automatic: If first appeal denied
  • Timeline: Additional 30 days for review
  • Requirements: No new documentation needed unless requested

External Review Through Ohio Department of Insurance

When Cigna's internal appeals are exhausted, Ohio residents can request an independent external review.

Eligibility Requirements:

  • Completed all Cigna internal appeals
  • Denial based on medical necessity or experimental status
  • Request filed within 180 days of final Cigna denial
  • Applies to state-regulated plans (not self-funded ERISA plans)

Filing Process:

  1. Contact ODI: Call 1-800-686-1526 or visit Ohio Department of Insurance
  2. Submit Documentation: Denial letters, medical records, provider statements
  3. IRO Assignment: Independent Review Organization conducts medical review
  4. Decision Timeline: 30 days standard, 72 hours expedited, 7 days for terminal conditions

IRO Decision: Binding on Cigna if coverage is approved; you retain other legal rights if denied.

Note: Self-funded employer plans follow federal ERISA rules rather than Ohio's external review process. Contact your HR department to confirm your plan type.

Cost and Savings Options

Estimated Costs:

  • Cash price: ~$1,900-$2,100 per month (30 tablets)
  • With insurance: Varies by plan (typically Tier 4 specialty copay)

Savings Programs:

  • Kyowa Kirin Patient Support: Copay assistance for eligible patients
  • Specialty pharmacy programs: Accredo may offer additional support
  • Foundation grants: Limited availability for qualifying patients

Contact manufacturer directly for current program details and eligibility requirements.

When to Escalate

Contact Ohio Department of Insurance if:

  • Cigna improperly denies external review eligibility
  • Review timelines are exceeded
  • You need guidance on the appeals process
  • Phone: 1-800-686-1526
  • Website: insurance.ohio.gov

Consider Legal Consultation for:

  • ERISA plan disputes
  • Repeated denials despite meeting criteria
  • Significant delays affecting health

Clinician Corner: Medical Necessity Letter

Essential Components:

  1. Patient diagnosis: Parkinson's disease with motor fluctuations
  2. Current therapy: Carbidopa/levodopa with documented limitations
  3. Step therapy failures: Specific medications tried, dates, outcomes
  4. Clinical rationale: Why Nourianz is medically necessary
  5. Supporting evidence: FDA approval, clinical guidelines, peer-reviewed studies
  6. Monitoring plan: Follow-up schedule and safety assessments

Key Clinical Evidence:

  • FDA approval for OFF episodes in Parkinson's disease
  • Clinical trials showing 1-1.6 hour reduction in daily OFF time
  • Unique adenosine A2A receptor mechanism
  • Safety profile in combination with levodopa

Frequently Asked Questions

Q: How long does Cigna prior authorization take in Ohio? A: Standard review takes 72 hours; expedited review takes 24 hours when medical urgency is documented.

Q: What if Nourianz is non-formulary on my plan? A: Request a formulary exception through your neurologist with clinical justification for medical necessity.

Q: Can I request expedited review? A: Yes, if delays would seriously jeopardize your health or current treatment stability.

Q: Does step therapy apply if I failed medications outside Ohio? A: Yes, documented failures from previous providers/states count toward step therapy requirements.

Q: What's the difference between internal and external appeals? A: Internal appeals are reviewed by Cigna; external appeals use independent medical experts through Ohio Department of Insurance.

Q: How much does Nourianz cost with insurance? A: Costs vary by plan; typically requires specialty pharmacy copay (often $100-500+ monthly for Tier 4 drugs).

Counterforce Health specializes in turning insurance denials into successful approvals by creating targeted, evidence-backed appeals. The platform analyzes denial letters and payer policies to identify specific coverage criteria, then drafts point-by-point rebuttals using the right clinical evidence and procedural requirements. For complex cases like Nourianz prior authorizations, having expert support can significantly improve approval rates and reduce the time spent navigating insurance requirements.

Whether you're facing an initial denial or preparing your first prior authorization request, Counterforce Health can help ensure your submission meets Cigna's specific requirements and maximizes your chances of approval.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with Cigna and consult your healthcare provider for medical decisions. For official Ohio insurance regulations and external review processes, contact the Ohio Department of Insurance at 1-800-686-1526.

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