By Counterforce Health Team in Voxzogo (vosoritide) —

Do You Qualify for Voxzogo (Vosoritide) Coverage by Cigna in Pennsylvania? Complete Decision Tree & Appeal Guide

Quick Answer: Voxzogo (Vosoritide) Coverage by Cigna in Pennsylvania

If your child has achondroplasia with open growth plates and you're in Pennsylvania, you likely qualify for Voxzogo coverage through Cigna. The fastest path: 1) Confirm FGFR3 genetic testing and growth plate imaging are complete, 2) Have your pediatric endocrinologist submit prior authorization with all required documentation, 3) If denied, use Pennsylvania's new external review program—about 50% of appeals succeed. Start by calling Cigna at the number on your insurance card to verify formulary status and PA requirements.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible" - Your Action Plan
  4. If "Possibly Eligible" - Additional Steps
  5. If "Not Yet Eligible" - Alternative Options
  6. If Denied - Pennsylvania Appeal Process
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & How to Fix Them
  9. Frequently Asked Questions
  10. Resources & Next Steps

How to Use This Decision Tree

This guide helps families and clinicians navigate Cigna's specific requirements for Voxzogo (vosoritide) coverage in Pennsylvania. Work through each section in order—the eligibility triage will tell you which path to follow based on your child's current situation.

Before you start, gather:

  • Insurance card and policy information
  • Recent medical records and growth charts
  • Any prior genetic testing results
  • List of previous treatments tried

Eligibility Triage: Do You Qualify?

Step 1: Diagnosis Confirmation

Does your child have a confirmed diagnosis of achondroplasia?

✅ YES - Genetic testing shows FGFR3 pathogenic variant (usually c.1138G>A or c.1138G>C)
→ Continue to Step 2

❓ UNSURE - Clinical features suggest achondroplasia but no genetic testing
→ See "Possibly Eligible" section

❌ NO - Different form of short stature or no genetic confirmation
→ See "Not Yet Eligible" section

Step 2: Growth Plate Status

Does imaging confirm your child has open epiphyses (growth plates)?

✅ YES - Recent X-ray or MRI shows actively growing growth plates
→ Continue to Step 3

❓ UNSURE - No recent imaging or unclear results
→ See "Possibly Eligible" section

❌ NO - Growth plates are closed
→ See "Not Yet Eligible" section

Step 3: Specialist Care

Is your child under care of a pediatric endocrinologist or medical geneticist?

✅ YES - Currently seeing appropriate specialist
→ LIKELY ELIGIBLE - Proceed to action plan

❓ UNSURE - Seeing pediatrician but no specialist referral yet
→ See "Possibly Eligible" section

❌ NO - No specialist involvement
→ See "Possibly Eligible" section

If "Likely Eligible" - Your Action Plan

Document Checklist for Prior Authorization

Your pediatric endocrinologist will need to submit these documents to Cigna:

Required Clinical Documentation:

  • Genetic test report confirming FGFR3 pathogenic variant
  • Growth plate imaging (X-ray or MRI) showing open epiphyses
  • Specialist consultation note from pediatric endocrinologist
  • Growth charts specific to achondroplasia
  • Baseline height and weight measurements
  • Documentation that child is not undergoing limb-lengthening surgery
  • Confirmation of no concurrent growth hormone therapy

Cigna-Specific Forms:

Submission Process

  1. Provider submits PA request through Cigna provider portal or fax
  2. Standard review timeline: Up to 72 hours for determination
  3. Expedited review available if medically urgent (24-hour timeline)
  4. Follow up within 3 business days if no response
Tip: BioMarin RareConnections offers free support with prior authorization paperwork and can provide template letters. Contact them at biomarin-rareconnections.com.

If "Possibly Eligible" - Additional Steps

Missing Genetic Testing

Next step: Request FGFR3 targeted genetic testing from your pediatrician or geneticist. This test:

  • Detects nearly 99% of achondroplasia cases
  • Usually covered by insurance when medically indicated
  • Takes 1-2 weeks for results

Missing Growth Plate Imaging

Next step: Schedule X-ray of hand/wrist or knee to confirm open growth plates. Your pediatric endocrinologist can order this imaging.

No Specialist Referral

Next step: Request referral to pediatric endocrinologist. In Pennsylvania, major children's hospitals with specialists include:

  • Children's Hospital of Philadelphia (CHOP)
  • UPMC Children's Hospital of Pittsburgh
  • Penn State Children's Hospital

Timeline to reapply: Once you have missing documentation, the prior authorization process typically takes 2-3 weeks.

If "Not Yet Eligible" - Alternative Options

Closed Growth Plates

Unfortunately, Voxzogo is only FDA-approved for children with open growth plates. Alternative options to discuss with your specialist:

  • Supportive care and monitoring
  • Orthopedic interventions if needed
  • Clinical trials (check ClinicalTrials.gov)

Non-Achondroplasia Diagnosis

Voxzogo is specifically approved only for achondroplasia. Consider:

  • Genetic counseling to confirm diagnosis
  • Alternative treatments for your child's specific condition
  • Second opinion from pediatric geneticist

Formulary Exception Request

Even if not traditionally covered, you can request a formulary exception. Your doctor must demonstrate:

  • Medical necessity for your specific case
  • Why alternatives aren't appropriate
  • Clinical evidence supporting off-label use (if applicable)

If Denied - Pennsylvania Appeal Process

Pennsylvania has a robust appeals system with high success rates. About 50% of external appeals are overturned in favor of patients.

Internal Appeal (First Step)

Timeline: Must file within 180 days of denial Process: Submit through Cigna member portal or mail Documents needed:

  • Denial letter
  • Additional medical records
  • Updated medical necessity letter

Pennsylvania External Review (If Internal Appeal Fails)

Timeline: Must file within 4 months of final internal denial Process: Submit through Pennsylvania Insurance Department Cost: Free to patient Success rate: Approximately 50% overturn rate

External Review Requirements:

Expedited Appeals

Available when delay could jeopardize health:

  • Internal expedited: 72 hours
  • External expedited: 72 hours
  • Requires physician certification of urgency
From our advocates: In a recent case, a family in Pennsylvania successfully overturned a Voxzogo denial by providing additional growth velocity data and emphasizing the time-sensitive nature of treatment during the child's growth period. The external reviewer agreed that delaying treatment could permanently impact the child's final adult height.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
FGFR3 genetic test Confirmed achondroplasia diagnosis Lab report from genetics testing Cigna Policy
Open growth plates Active bone growth potential X-ray or MRI imaging report Cigna Policy
Specialist care Pediatric endocrinologist oversight Consultation notes Cigna Policy
Age requirement Pediatric patients (≥2 years old) Medical records FDA Label
No limb lengthening Cannot be concurrent with surgery Orthopedic records Cigna Policy

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"Genetic testing not provided" Submit FGFR3 lab report showing pathogenic variant
"Growth plates not confirmed open" Provide recent imaging (X-ray/MRI) with radiologist interpretation
"Not prescribed by specialist" Obtain consultation from pediatric endocrinologist
"Medical necessity not established" Submit comprehensive letter addressing growth velocity, family impact, and treatment goals
"Experimental/investigational" Cite FDA approval and Cigna's own policy recognizing coverage

Frequently Asked Questions

How long does Cigna prior authorization take in Pennsylvania? Standard review is completed within 72 hours. Expedited review (for urgent cases) is completed within 24 hours.

What if Voxzogo is non-formulary on my plan? You can request a formulary exception. Your doctor must provide clinical rationale for why Voxzogo is medically necessary and why alternatives aren't appropriate.

Can I request an expedited appeal? Yes, if delay in treatment would jeopardize your child's health. This requires physician certification and is decided within 72 hours for both internal and external appeals.

Does step therapy apply to Voxzogo? No, there are no FDA-approved alternatives for achondroplasia, so step therapy typically doesn't apply. However, some plans may require documentation that supportive care alone is insufficient.

What if I already paid out-of-pocket during the appeal? If your appeal is successful, Cigna must provide retroactive coverage and reimburse you for covered expenses during the appeal period.

How much does Voxzogo cost? The list price is approximately $320,000 per year before insurance and rebates. Actual cost varies by weight and payer contracts. BioMarin RareConnections offers financial assistance programs for eligible families.

Can I get help with the appeals process? Yes, Pennsylvania offers free consumer assistance through the Pennsylvania Health Law Project and the Insurance Department's consumer services.

What happens if Pennsylvania's external review upholds the denial? The external reviewer's decision is binding on Cigna. However, you may have additional options through federal agencies if you believe the process was flawed.

Resources & Next Steps

Key Contacts

  • Cigna Customer Service: Number on your insurance card
  • BioMarin RareConnections: biomarin-rareconnections.com - Free PA and appeal support
  • Pennsylvania Insurance Department: pa.gov/insurance - External review and consumer assistance
  • Pennsylvania Health Law Project: phlp.org - Free legal assistance

Official Documentation

Getting Additional Help

If you're navigating a complex prior authorization or appeal, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to create point-by-point rebuttals that align with payers' own rules, pulling the right clinical evidence and procedural requirements to maximize approval chances.

For families in Pennsylvania dealing with Cigna denials, the combination of the state's new external review program and comprehensive appeal preparation has led to significantly improved outcomes for specialty drug coverage.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare providers and insurance company for decisions about your specific situation. Coverage policies and appeal processes may change; verify current requirements with Cigna and the Pennsylvania Insurance Department.

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