By Counterforce Health Team in Crysvita (burosumab) —

Get Crysvita (Burosumab) Covered by UnitedHealthcare in Georgia: Complete Guide with Forms, Appeals, and Contacts

Answer Box: Getting Crysvita Covered by UnitedHealthcare in Georgia

Fastest path to approval: Submit a prior authorization through UnitedHealthcare's provider portal with genetic testing or elevated FGF23 results, specialist prescription, and documented low serum phosphorus. Adults need proof of failed oral phosphate plus calcitriol therapy first. If denied, you have 180 days for internal appeal and 60 days for Georgia external review. Start today: Verify your plan requires PA through OptumRx and gather your XLH diagnosis documentation.

Table of Contents

Verify Your Plan and Find the Right Policy

Before starting your Crysvita prior authorization, confirm your specific UnitedHealthcare plan type. The coverage criteria vary slightly between commercial, Medicare Advantage, and Medicaid plans.

Find your policy document:

  • Log into your member portal at uhc.com
  • Look for "Prescription Drug Coverage" or "Formulary"
  • Search for "burosumab" or "Crysvita"

UnitedHealthcare's current Crysvita policy (effective May 1, 2025) requires prior authorization for all plans and includes step therapy requirements for adults.

Required Forms and Current Versions

Prior Authorization Forms

UnitedHealthcare doesn't publish a Crysvita-specific form. Use the OptumRx General Prior Authorization Form for all requests:

Tip: Always verify you have the most current form by checking the OptumRx provider portal before submitting.

Medical Necessity Letter Template

Your physician should include these elements in the letter of medical necessity:

  1. Patient identification and confirmed XLH diagnosis
  2. Genetic testing results (PHEX mutation) or elevated FGF23 levels
  3. Laboratory values showing low serum phosphorus
  4. Prior treatment history (especially for adults: oral phosphate + calcitriol trials)
  5. Clinical rationale citing FDA labeling and treatment guidelines
  6. Specialist involvement confirmation

Online Portals for Submission

Provider Portal

Submit PA requests through the UnitedHealthcare Provider Portal:

  1. Log in to your provider account
  2. Navigate to "Prior Authorization and Notification Tool"
  3. Enter patient, diagnosis, and medication details
  4. Upload supporting documentation directly
  5. Submit electronically for fastest processing

Member Portal Access

Patients can track PA status through their member portal but cannot submit initial requests. You'll need your provider to handle the submission.

Fax Numbers and Mailing Addresses

Appeals and Urgent Requests

  • Urgent appeals fax: 801-994-1261, 888-808-9123, or 866-373-1081

Standard appeals mail:

UnitedHealthcare Member Grievance & Appeals
P.O. Box 31364
Salt Lake City, UT 84131-0364

Prior Authorization Fax

  • OptumRx PA fax: 1-844-403-1027
Note: Mark urgent appeals clearly and include "URGENT" on cover sheets for expedited review.

Specialty Pharmacy Network

Crysvita must be dispensed through UnitedHealthcare's contracted specialty pharmacy network, primarily Optum Specialty Pharmacy.

Patient Onboarding Process

  1. Provider sends prescription to Optum Specialty Pharmacy
  2. Optum coordinates prior authorization review
  3. Patient care coordinators contact you for enrollment
  4. Support includes: medication delivery, administration training, adherence monitoring

Patient contact: 1-855-427-4682 for enrollment and questions.

Member and Provider Support Lines

Key Phone Numbers

  • General Provider Services: 877-842-3210
  • Medicare Advantage: 800-542-8789
  • Medicaid/Community Plan: 866-270-5785
  • General Customer Service: 1-888-842-4571
  • OptumRx Urgent PA: 1-800-711-4555

When calling, have ready: member ID, group number, prescriber NPI, and specific questions about Crysvita coverage.

Georgia Consumer Protection and Appeals

Georgia provides strong consumer protections for insurance denials through the Georgia Department of Insurance.

External Review Process

If UnitedHealthcare denies your internal appeal, you can request external review:

  • Deadline: 60 days from final internal denial letter
  • Cost: Free to consumers
  • Timeline: 30 business days (72 hours for urgent cases)
  • Contact: Georgia Department of Insurance Consumer Services at 1-800-656-2298

State Resources

  • Georgia Department of Insurance: oci.ga.gov for external review applications
  • Georgians for a Healthy Future: Consumer assistance and appeal guidance
  • Georgia Legal Services Program: Help with Medicaid appeals

Coverage Requirements at a Glance

Requirement Details Documentation Needed
Diagnosis X-linked hypophosphatemia (XLH) confirmed Genetic testing (PHEX mutation) OR elevated FGF23 >30 pg/mL
Age ≥6 months old Birth certificate or medical records
Lab Values Fasting serum phosphorus below normal range Recent lab results (within 3 months)
Specialist Endocrinologist or metabolic bone specialist Prescription and consultation notes
Step Therapy (Adults) Failed oral phosphate + calcitriol Documentation of trials, failures, or contraindications
Prior Authorization Required for all plans Complete PA form with clinical documentation

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient/Family)

  • Insurance cards and member ID
  • Complete medical records showing XLH diagnosis
  • Genetic test results or FGF23 lab values
  • Previous treatment history and outcomes

2. Specialist Consultation (Provider)

  • Confirm XLH diagnosis with appropriate testing
  • Document clinical rationale for Crysvita
  • For adults: document failed conventional therapy

3. Submit Prior Authorization (Provider)

  • Use OptumRx General PA Form
  • Submit via provider portal or fax to 1-844-403-1027
  • Include all supporting clinical documentation

4. Follow Up (Both)

  • Standard review: 15 business days
  • Urgent review: 72 hours
  • Track status through provider portal

5. If Denied: Internal Appeal (Provider)

  • Submit within 180 days of denial
  • Include additional clinical evidence
  • Request peer-to-peer review if available

6. If Still Denied: External Review (Patient)

  • File with Georgia DOI within 60 days
  • Submit application and supporting documents
  • Await independent medical review decision

7. Specialty Pharmacy Setup (Patient)

  • Enroll with Optum Specialty Pharmacy
  • Complete onboarding and training
  • Schedule regular medication deliveries

Common Denial Reasons and Solutions

Denial Reason Solution
Missing genetic testing Submit PHEX mutation results or elevated FGF23 levels
Insufficient lab values Provide recent fasting serum phosphorus below normal range
Step therapy not met Document failed trials of oral phosphate + calcitriol (adults)
Wrong specialist Ensure prescription from endocrinologist or metabolic bone specialist
Concurrent medications Discontinue oral phosphate and active vitamin D before starting
Incomplete documentation Submit comprehensive medical records and clinical notes

Appeals Process for Georgia

Internal Appeals (UnitedHealthcare)

  • Timeline: 180 days from denial date
  • Process: Submit written appeal with additional evidence
  • Decision: 30 days for standard, 72 hours for urgent
  • Contact: Mail to appeals address or fax to urgent numbers above

External Review (Georgia DOI)

  • Eligibility: After exhausting internal appeals
  • Timeline: 60 days from final internal denial
  • Process: Submit application to Georgia Department of Insurance
  • Decision: 30 business days (72 hours urgent)
  • Binding: Insurer must comply with favorable decisions

Georgia's external review process has helped many patients overturn wrongful denials for specialty medications like Crysvita.

Costs and Patient Assistance

Crysvita Pricing (2024)

  • 10 mg/mL vial: $4,451.45 WAC
  • 20 mg/mL vial: $8,902.91 WAC
  • 30 mg/mL vial: $13,354.36 WAC

Total monthly cost depends on weight-based dosing (every 2-4 weeks)

Patient Assistance Options

  • Manufacturer support: Check Crysvita HCP website for copay assistance programs
  • Foundation grants: Research rare disease foundations offering financial aid
  • State programs: Georgia may offer additional assistance through Medicaid waiver programs

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals through evidence-backed strategies. Our platform analyzes denial letters and plan policies to identify specific coverage gaps, then drafts targeted rebuttals with the right clinical evidence and procedural requirements. For complex cases like Crysvita approvals, having expert support can make the difference between coverage and continued denials. Learn more at CounterforceHealth.org.

FAQ

How long does UnitedHealthcare prior authorization take for Crysvita in Georgia? Standard PA reviews take 15 business days. Urgent requests are processed within 72 hours when clinical urgency is documented.

What if Crysvita isn't on my UnitedHealthcare formulary? Crysvita requires prior authorization on most UnitedHealthcare plans but is typically covered when medical necessity criteria are met. Non-formulary status may require additional documentation.

Can I request an expedited appeal in Georgia? Yes, both UnitedHealthcare internal appeals and Georgia external reviews offer expedited processes for urgent medical situations, typically decided within 72 hours.

Does step therapy apply if I failed treatments outside Georgia? Treatment history from any location counts toward step therapy requirements. Provide documentation of failed oral phosphate and calcitriol trials regardless of where they occurred.

What counts as medical necessity for Crysvita? Medical necessity requires confirmed XLH diagnosis, appropriate age (≥6 months), low serum phosphorus, specialist prescription, and for adults, documented failure of conventional therapy.

Can I use external review for any UnitedHealthcare denial in Georgia? Georgia external review applies to fully insured plans and covers denials based on medical necessity, experimental/investigational determinations, and similar utilization management decisions.

From our advocates: "We've seen Crysvita approvals succeed when families gather comprehensive genetic testing results upfront and work closely with their endocrinologist to document the complete treatment history. The key is showing clear medical necessity and, for adult patients, why conventional therapies haven't worked. This preparation makes both initial PA submissions and appeals much stronger."

When working with complex specialty drug approvals, having experienced guidance can significantly improve your chances of success. Counterforce Health specializes in turning insurance denials into targeted appeals by analyzing your specific plan's requirements and crafting evidence-based responses that address each coverage criterion.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice or a guarantee of coverage. Always consult with your healthcare provider about treatment decisions and verify current policy requirements with your insurer. For legal advice about insurance disputes, consult with a qualified attorney. Coverage policies and procedures may change; confirm current requirements with official sources.

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