By Counterforce Health Team in Voxzogo (vosoritide) —

Do You Qualify for Voxzogo (Vosoritide) Coverage by Aetna CVS Health in New Jersey? Complete Decision Tree & Appeals Guide

Answer Box: Voxzogo Coverage by Aetna CVS Health in New Jersey

Who qualifies: Children with achondroplasia, open growth plates, and specialist prescription. Fastest path: Gather genetic testing (FGFR3 mutation), growth plate imaging, and baseline growth data. Submit PA through CVS Caremark at 1-800-294-5979. If denied: Use New Jersey's Independent Health Care Appeals Program (IHCAP) through Maximus Federal Services within 180 days. First step today: Call Aetna member services to confirm current PA requirements and download forms.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible": Document Checklist
  4. If "Possibly Eligible": Tests to Request
  5. If "Not Yet": Alternative Options
  6. If Denied: New Jersey Appeal Path
  7. Coverage Requirements at a Glance
  8. Appeals Playbook for Aetna CVS Health
  9. Common Denial Reasons & Solutions
  10. Costs & Patient Assistance
  11. FAQ

How to Use This Decision Tree

This guide helps families navigate Voxzogo (vosoritide) coverage through Aetna CVS Health in New Jersey. Work through each section in order—starting with the eligibility triage—to determine your strongest path to approval.

What you'll need before starting:

  • Insurance card and member ID
  • Child's medical records
  • Recent growth measurements
  • Any prior therapy documentation

If you're already denied, skip to the appeals section for immediate next steps.

Eligibility Triage: Do You Qualify?

Answer these questions to determine your coverage likelihood:

✅ Likely Eligible (Green Light)

  • Child has confirmed achondroplasia diagnosis
  • Growth plates are open (confirmed by recent X-ray or bone age study)
  • Prescribed by pediatric endocrinologist, geneticist, or neurologist
  • Have genetic testing showing FGFR3 mutation OR clinical symptoms plus X-ray findings
  • Child is under 18 years old

⚠️ Possibly Eligible (Yellow Light)

  • Achondroplasia suspected but genetic testing incomplete
  • Growth plate status unknown or outdated imaging
  • Prescribed by general pediatrician (may need specialist consultation)
  • Missing baseline growth velocity data

🛑 Not Yet (Red Light)

  • No confirmed achondroplasia diagnosis
  • Closed growth plates
  • Over 18 years old
  • No specialist involvement

If "Likely Eligible": Document Checklist

You're on the fastest track to approval. Aetna's coverage policy requires these documents:

Required Documentation

  • Genetic testing report confirming FGFR3 mutation
  • Recent imaging (within 6 months) showing open epiphyses
  • Specialist prescription from pediatric endocrinologist, geneticist, or neurologist
  • Baseline growth data including height velocity measurements
  • Medical records documenting achondroplasia diagnosis and clinical features

Submission Path

  1. Call CVS Caremark Prior Authorization: 1-800-294-5979
  2. Request peer-to-peer review if initial submission needs clarification
  3. Submit through provider portal or fax (verify current fax with CVS Caremark)
  4. Timeline: Standard PA decisions within 15 days; expedited within 72 hours if urgent
Tip: BioMarin RareConnections provides PA templates and can help coordinate documentation. Call 1-833-869-9646.

If "Possibly Eligible": Tests to Request

You need additional documentation before submitting your PA:

Missing Genetic Testing

  • Request FGFR3 mutation testing from your geneticist or endocrinologist
  • Alternative: Clinical diagnosis with characteristic X-ray findings may suffice per Aetna policy
  • Timeline: Genetic testing results typically take 2-4 weeks

Unknown Growth Plate Status

  • Request bone age study or growth plate X-rays
  • Must show open epiphyses for coverage approval
  • Re-evaluate annually as growth plates close with age

Specialist Consultation Needed

  • Refer to pediatric endocrinologist or geneticist
  • Use Voxzogo's doctor finder to locate specialists in New Jersey
  • Document specialist consultation in medical records before PA submission

If "Not Yet": Alternative Options

Diagnosis Confirmation Needed

  • Genetic counseling consultation to evaluate for achondroplasia
  • Clinical evaluation by pediatric geneticist
  • Family history review and physical examination

Closed Growth Plates

  • No FDA-approved pharmacologic alternatives currently available
  • Supportive care options: physical therapy, orthopedic monitoring
  • Investigational therapies: infigratinib (FGFR3 inhibitor) in clinical trials but not approved

Exception Request Strategy

Even if standard criteria aren't met, you can request a formulary exception through Aetna's appeals process with strong clinical justification.

If Denied: New Jersey Appeal Path

New Jersey offers excellent consumer protections through the Independent Health Care Appeals Program (IHCAP). Here's your roadmap:

Level 1: Internal Appeal with Aetna

  • Timeline: Submit within 180 days of denial
  • Process: Submit additional documentation addressing denial reasons
  • Decision: Within 15 days (72 hours if expedited)
  • Contact: CVS Caremark Prior Authorization at 1-800-294-5979

Level 2: New Jersey External Review (IHCAP)

  • When: After completing Aetna's internal appeal process
  • Timeline: Submit within 180 days of final internal denial
  • Process: Submit directly to Maximus Federal Services
  • Decision: Within 45 days (expedited reviews much faster)
  • Cost: Free to patients
  • Binding: Aetna must comply with IURO decision
Note: About 50% of external reviews nationwide favor patients, giving you strong odds if you have solid clinical documentation.

New Jersey Consumer Assistance

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization PA required before dispensing CVS Caremark portal Aetna Policy
Specialist Prescription Endocrinologist, geneticist, or neurologist Provider credentials Aetna Policy
Genetic Testing FGFR3 mutation confirmation Lab report Aetna Policy
Open Growth Plates Imaging within 6 months Radiology report Aetna Policy
Quantity Limit 30 vials per 30 days Prescription dosing Aetna Policy
Appeals Deadline 180 days from denial Denial letter New Jersey Insurance Law

Appeals Playbook for Aetna CVS Health

Step-by-Step Appeal Process

Step 1: Gather Your Denial Letter

  • Note specific denial reasons
  • Check appeals deadline (180 days from letter date)
  • Identify missing documentation

Step 2: Request Peer-to-Peer Review

  • Call CVS Caremark: 1-800-294-5979
  • Schedule prescriber discussion with Aetna medical director
  • No guaranteed timeline, but typically scheduled promptly

Step 3: Submit Internal Appeal

  • Address each denial reason with new documentation
  • Include detailed medical necessity letter from specialist
  • Submit within 180-day window

Step 4: If Still Denied, File External Review

  • Complete New Jersey IHCAP application
  • Submit to Maximus Federal Services (contact info provided by DOBI)
  • Include all medical records and specialist letters

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documents
Missing genetic testing Submit FGFR3 mutation report Lab results showing pathogenic variant
Growth plates not confirmed open Provide recent imaging Bone age study or X-ray within 6 months
Non-specialist prescriber Get specialist consultation Note from pediatric endocrinologist/geneticist
Insufficient growth data Document baseline measurements Growth velocity charts and height records
"Experimental/investigational" Cite FDA approval FDA approval letter and clinical evidence

Costs & Patient Assistance

Financial Support Options

  • BioMarin RareConnections: Co-pay assistance for eligible commercially insured patients
  • Enrollment: Call 1-833-869-9646 or complete Patient Consent Form
  • Restrictions: Not available with government-funded healthcare programs

Cost Context

  • List price: Approximately $320,000 annually before rebates
  • Actual cost: Varies significantly based on insurance contracts and patient weight
  • Specialty pharmacy: Dispensed through CVS Specialty Pharmacy after approval
From Our Advocates: We've seen families successfully appeal initial denials by working closely with their pediatric endocrinologist to document growth velocity improvements from previous measurements. The key was showing clear medical necessity through detailed growth charts and specialist attestation of treatment goals.

FAQ

How long does Aetna CVS Health PA take in New Jersey? Standard prior authorization decisions are made within 15 days. Expedited reviews for urgent cases are completed within 72 hours.

What if Voxzogo is non-formulary on my plan? You can request a formulary exception through Aetna's appeals process. Provide clinical documentation showing medical necessity and lack of formulary alternatives.

Can I request an expedited appeal? Yes, if delay would cause serious harm to your child's health. Your physician must certify medical urgency for expedited processing.

Does step therapy apply to Voxzogo? No, there are no FDA-approved pharmacologic alternatives for achondroplasia, so step therapy typically doesn't apply.

What happens if external review favors my case? The decision is binding—Aetna must provide coverage and reimburse any services already received if applicable.

Can my doctor file the external review for me? Yes, New Jersey allows providers to file external appeals on behalf of patients with proper consent.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Voxzogo. Our platform analyzes denial letters, identifies coverage gaps, and creates evidence-backed appeals that align with payer-specific requirements. We help patients, clinicians, and specialty pharmacies navigate prior authorization challenges with targeted documentation and proven appeal strategies.

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 contact your insurance plan directly for the most current coverage policies and procedures. For assistance with New Jersey insurance appeals, contact the Department of Banking and Insurance at 1-800-446-7467.

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