CurrentCignaPolicy N/A

Parkinson's Disease - Nourianz Prior Authorization Policy

This policy governs prior authorization and coverage criteria for Nourianz (istradefylline) as adjunctive treatment to carbidopa/levodopa for adults with Parkinson's disease experiencing 'off' episodes for Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyParkinson's Disease - Nourianz Prior Authorization Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review DateMar 25, 2026

Key ActionObtain prior authorization and document that the patient is taking carbidopa/levodopa, is experiencing 'off' episodes, and that the medication is prescribed by or in consultation with a neurologist.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yearapproval duration

FDA-approvedindication described

Not coveredexclusion scope

Neurologistspecialist requirement

Coverage Criteria for Nourianz (istradefylline)

Initial/Approved Indication

Covered when ALL of the following are met

FDA-Approved Indication Criteria

A: Patient is currently taking carbidopa/levodopa
B: Patient is experiencing 'off' episodes
Examples of 'off' episodes include muscle stiffness, slow movements, or difficulty starting movements.
C: Medication is prescribed by or in consultation with a neurologist

Policy Summary

PayerCigna

PolicyParkinson's Disease - Nourianz Prior Authorization Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review DateMar 25, 2026

SourceLink

On This Page

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Prior authorization is required; approvals are provided for 1 year when criteria are met.

Nourianz (istradefylline) is not medically necessary for any use(s) other than the FDA‑approved indication described in this policy. Requests for coverage for indications outside the specified adjunctive use will be denied.

Any indication or use that does not meet the FDA‑approved adjunctive indication for Nourianz in Parkinson’s disease with documented ‘off’ episodes is considered not medically necessary and is not covered under this policy.

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is recommended and required for coverage. Approvals are provided for 1 year when criteria are met.

Prior authorization required
Approval duration: 1 year

Note

Specialist Prescriber Requirement

Approval requires that Nourianz be prescribed by or in consultation with a physician who specializes in the condition being treated (neurologist).

Prescriber requirement: neurologist or in consultation with a neurologist

Documentation Required

Required Clinical Documentation

Provider must document that the patient is currently taking carbidopa/levodopa and is experiencing 'off' episodes. Examples of 'off' episodes include muscle stiffness, slow movements, or difficulty starting movements.

Documentation required: current use of carbidopa/levodopa
Documentation required: evidence of 'off' episodes (e.g., muscle stiffness, bradykinesia, difficulty initiating movement)

Denial Risk

Non‑covered Uses

Requests for Nourianz for any use other than adjunctive treatment to carbidopa/levodopa for Parkinson's disease 'off' episodes will be denied as not medically necessary.

Non-covered uses: any indication other than adjunctive treatment to carbidopa/levodopa for Parkinson's disease 'off' episodes

Background

Nourianz (istradefylline) is an oral adenosine A2A receptor antagonist marketed as an adjunctive treatment to carbidopa/levodopa for adults with Parkinson’s disease who experience ‘off’ episodes. This policy limits coverage to the FDA‑approved adjunctive indication; uses outside that indication are not covered.

Key Definitions

'Off' episodes — definition and examples

DefinitionEpisodes of worsening Parkinson's symptoms such as muscle stiffness, slow movements, or difficulty starting movements.

ContextThese 'off' episodes are the clinical phenomenon targeted by adjunctive therapy with Nourianz (istradefylline).

ExamplesMuscle stiffness; slow movements (bradykinesia); difficulty initiating movements (akinesia).

Documentation requirementProvider must document presence of 'off' episodes when requesting coverage for adjunctive therapy.