By Counterforce Health Team in Nourianz (istradefylline) —

How to Get Nourianz (Istradefylline) Covered by Cigna in Washington: Appeals, Forms & Timeline Guide

Answer Box: Getting Nourianz (Istradefylline) Covered by Cigna in Washington

Nourianz (istradefylline) requires prior authorization from Cigna and often faces step therapy requirements. Most denials stem from missing documentation of failed trials with amantadine, MAO-B inhibitors (rasagiline, safinamide), and COMT inhibitors (entacapone, opicapone).

First step today: Contact your neurologist to document your "OFF" episodes with a daily diary and gather records showing previous medication failures. Submit a complete prior authorization request through Cigna's provider portal or Express Scripts. If denied, you have 180 days to file an internal appeal, followed by external review through Washington's Independent Review Organization (IRO) process.

Key requirement: You must be on levodopa/carbidopa and experiencing at least 3 hours daily of "OFF" time despite optimized therapy.

Table of Contents

  1. Understanding Cigna's Coverage Requirements
  2. Common Denial Reasons & How to Fix Them
  3. Step-by-Step: Fastest Path to Approval
  4. Medical Necessity Documentation
  5. Appeals Process in Washington
  6. Templates & Scripts
  7. Costs & Patient Support
  8. When to Escalate
  9. FAQ

Understanding Cigna's Coverage Requirements

Nourianz (istradefylline) is a specialty medication that Cigna typically manages through Express Scripts and dispenses via Accredo specialty pharmacy. The drug costs approximately $1,900-$2,100 per month without insurance coverage.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all members Cigna formulary Cigna PA Policy
Step Therapy Must try 3+ alternatives first PA form requirements Cigna policy documents
Formulary Status Tier 4 specialty (verify with plan) Plan documents Member portal
Quantity Limits 30-day supply typical Pharmacy benefit Express Scripts
Diagnosis Requirement Parkinson's disease with OFF episodes ICD-10: G20 FDA labeling
Concurrent Therapy Must be on levodopa/carbidopa Medical records Clinical documentation

Common Denial Reasons & How to Fix Them

1. Step Therapy Not Completed

Fix: Document trials and failures of:

  • Amantadine (immediate or extended-release)
  • MAO-B inhibitor (rasagiline, safinamide, or selegiline)
  • COMT inhibitor (entacapone, opicapone, or tolcapone)

Include pharmacy records, prescriber notes, and specific reasons for discontinuation (ineffective, side effects, contraindications).

2. Insufficient OFF Episode Documentation

Fix: Provide a detailed daily diary showing:

  • Duration of OFF episodes (≥3 hours daily)
  • Specific symptoms (stiffness, slowness, difficulty moving)
  • Impact on daily activities
  • Timing relative to medication doses

3. Missing Concurrent Levodopa Documentation

Fix: Submit current prescription records showing active levodopa/carbidopa therapy with dosing and frequency.

4. Incomplete Medical Records

Fix: Ensure submission includes:

  • Neurologist or movement disorder specialist notes
  • Parkinson's diagnosis confirmation
  • UPDRS scores or functional assessments
  • Treatment history and outcomes

Step-by-Step: Fastest Path to Approval

1. Gather Documentation (Patient & Clinic)

  • Insurance card and member ID
  • Complete medication history with dates and outcomes
  • Daily OFF episode diary (minimum 2 weeks)
  • Recent neurologist visit notes
  • Timeline: 1-2 weeks to collect

2. Submit Prior Authorization (Prescriber)

  • Complete Cigna PA form with all required fields
  • Attach supporting documentation
  • Submit via provider portal or fax to Express Scripts
  • Timeline: 72 hours for standard review, 24 hours for expedited

3. Monitor Decision (Patient)

  • Check member portal or call customer service
  • Request written denial if coverage is denied
  • Note appeal deadline (180 days from denial date)
  • Timeline: Decision within 3 business days

4. File Internal Appeal if Denied (Patient/Prescriber)

  • Submit appeal letter with additional evidence
  • Request peer-to-peer review if available
  • Include any new clinical information
  • Timeline: 30 days for standard, 72 hours for expedited

5. Request External Review if Needed (Patient)

  • File with Washington Office of Insurance Commissioner
  • Submit IRO external review request form
  • Provide all denial and appeal documentation
  • Timeline: 30 days for IRO decision

Medical Necessity Documentation

Clinician Corner: Essential Elements

Your medical necessity letter should include:

1. Patient Demographics & Diagnosis

  • Confirmed Parkinson's disease diagnosis (ICD-10: G20)
  • Duration of illness and current Hoehn & Yahr stage
  • Current levodopa/carbidopa regimen and duration

2. Documentation of Motor Fluctuations

  • Specific description of OFF episodes
  • Quantified daily OFF time (≥3 hours recommended)
  • Functional impact on activities of daily living
  • UPDRS scores or other validated assessments

3. Prior Treatment History

  • Complete list of previous Parkinson's medications
  • Specific reasons for discontinuation or inadequate response
  • Documentation of step therapy completion:
    • Amantadine trial (dose, duration, outcome)
    • MAO-B inhibitor trial (specify agent, outcome)
    • COMT inhibitor trial (specify agent, outcome)

4. Clinical Rationale

  • Why formulary alternatives are inappropriate
  • Expected benefits of istradefylline therapy
  • Treatment goals and monitoring plan

5. Supporting Evidence

  • Reference FDA approval for OFF episodes
  • Cite clinical trials demonstrating efficacy
  • Include relevant treatment guidelines

Appeals Process in Washington

Washington state provides robust consumer protections for insurance denials, including mandatory internal appeals and independent external review.

Internal Appeals (First Level)

  • Deadline: 180 days from denial date
  • Timeline: 30 days for standard review
  • How to file: Written request to Cigna member services
  • Required: Copy of denial, medical records, prescriber letter
  • Expedited option: Available if delay would seriously harm health

Internal Appeals (Second Level)

  • When: After first-level denial
  • Timeline: 30 days for review
  • Process: Automatic right to second review
  • Decision: Final internal determination

External Review (IRO)

  • Eligibility: After exhausting internal appeals
  • Deadline: 180 days from final internal denial
  • Process: File request with Washington Office of Insurance Commissioner
  • Timeline: 30 days for decision (72 hours if expedited)
  • Cost: Free to patient
  • Decision: Binding on insurer
Note: Washington's IRO process is particularly effective for specialty medications, with independent medical experts reviewing denials outside the insurer's influence.

Templates & Scripts

Patient Phone Script for Cigna

"Hello, I'm calling about a prior authorization denial for Nourianz, prescription number [X]. I'd like to understand the specific denial reasons and request information about filing an internal appeal. Can you also tell me if peer-to-peer review is available with the medical director?"

Appeal Letter Template

[Date]
Cigna Health Insurance
Appeals Department
[Address from denial letter]

RE: Appeal for Nourianz (Istradefylline) Denial
Member: [Name], ID: [Number]
Prescription: [Rx number]

Dear Appeals Review Team,

I am formally appealing the denial of coverage for Nourianz (istradefylline) dated [date]. This medication is medically necessary for my Parkinson's disease with motor fluctuations.

Key Points:
• I have completed required step therapy with [list specific medications and outcomes]
• I experience [X] hours daily of OFF episodes despite optimized levodopa therapy
• My neurologist has documented medical necessity in attached records
• Formulary alternatives are inappropriate because [specific reasons]

Attached Documentation:
- Copy of denial letter
- Neurologist's letter of medical necessity  
- Medication trial history
- Daily symptom diary
- Relevant medical records

I request coverage approval and ask that you expedite this review given my ongoing symptoms.

Sincerely,
[Signature]
[Contact information]

Costs & Patient Support

Manufacturer Support Programs

  • Kyowa Kirin Cares: Copay assistance and patient support
  • Eligibility: Commercial insurance required
  • Savings: Up to $X per month (verify current terms)
  • Contact: KyowaKirinCares.com

Alternative Funding Sources

  • Patient Advocate Foundation: Copay relief program
  • Parkinson's Foundation: Medication assistance
  • Washington state programs: Apple Health (Medicaid) coverage

Cash Pricing Options

  • GoodRx: Discount pricing at participating pharmacies
  • Manufacturer direct: Patient assistance program for uninsured
  • Specialty pharmacy: Payment plans through Accredo

When to Escalate

Washington Office of Insurance Commissioner

If your appeals are unsuccessful or you experience delays:

  • Consumer Hotline: 1-800-562-6900
  • Online complaint: insurance.wa.gov
  • What to include: All denial letters, appeal responses, timeline of events

Department of Health

For provider-related issues:

  • Contact: Washington State Department of Health
  • When to use: If prescriber faces barriers to submission

How Counterforce Health Can Help

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, identifying specific coverage gaps, and drafting evidence-backed responses. Their platform helps patients and providers navigate complex prior authorization requirements for specialty medications like Nourianz, ensuring all necessary documentation and medical necessity criteria are properly addressed in appeals submissions.

FAQ

Q: How long does Cigna prior authorization take for Nourianz in Washington? A: Standard review is 72 hours; expedited review is 24 hours if your prescriber indicates urgent medical need.

Q: What if Nourianz is non-formulary on my plan? A: You can request a formulary exception through Cigna's coverage determination process, requiring additional medical justification for why formulary alternatives are inappropriate.

Q: Can I request an expedited appeal in Washington? A: Yes, if waiting for standard review would seriously jeopardize your health. Your prescriber must document the urgent medical need.

Q: Does step therapy apply if I tried these medications outside Washington? A: Yes, medication trials from any location count toward step therapy requirements if properly documented with dates, doses, and outcomes.

Q: What happens if the IRO upholds Cigna's denial? A: The IRO decision is final for the insurance appeal process. You may explore alternative funding sources or consider formulary alternatives with your prescriber.

Q: How much does external review cost in Washington? A: External IRO review is free to patients. The insurer pays all costs associated with the independent review process.

Q: Can I continue current Parkinson's medications while appealing? A: Yes, continue your current regimen. Consider asking your prescriber about temporary alternatives or samples while the appeal is pending.

Q: What if my employer plan is self-funded? A: Self-funded ERISA plans may not be subject to Washington state appeal rights. Contact the U.S. Department of Labor for ERISA plan appeals guidance.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about treatment decisions and work with your prescriber to navigate insurance coverage requirements. For personalized assistance with appeals, consider consulting with patient advocacy organizations or services like Counterforce Health that specialize in insurance coverage navigation.

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