By Counterforce Health Team in Voxzogo (vosoritide) —

Get Voxzogo (Vosoritide) Covered by Blue Cross Blue Shield in Washington: Complete 2025 Guide

Answer Box: Getting Voxzogo Covered in Washington

Blue Cross Blue Shield Washington requires prior authorization for Voxzogo (vosoritide) in pediatric achondroplasia patients under 18 with open growth plates and confirmed FGFR3 variants. The fastest path: 1) Have your pediatric endocrinologist or geneticist gather genetic testing results and growth plate imaging, 2) Submit complete prior authorization with baseline growth data, 3) If denied, file internal appeal within 180 days. Washington's external review process through Independent Review Organizations (IROs) has strong consumer protections. Start by calling Blue Cross Blue Shield member services to confirm your plan's specific requirements.

Table of Contents

  1. Set Your Goal: What Approval Requires
  2. Visit Prep: Gathering Your Medical History
  3. Evidence Kit: Clinical Documentation
  4. Medical Necessity Letter Structure
  5. Peer-to-Peer Support Strategy
  6. After-Visit Documentation
  7. Respectful Persistence and Follow-Up
  8. Blue Cross Blue Shield Washington Appeal Process
  9. BioMarin RareConnections Support
  10. Frequently Asked Questions

Set Your Goal: What Approval Requires

Getting Voxzogo covered by Blue Cross Blue Shield in Washington starts with understanding exactly what your plan requires. All Blue Cross Blue Shield plans in Washington require prior authorization for Voxzogo, but specific criteria can vary between individual Blue plans like Premera Blue Cross and Regence BlueShield.

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed
Age Limit Patient under 18 years old Birth certificate or medical records
Diagnosis Confirmed achondroplasia with FGFR3 variant Genetic testing report
Growth Plates Open epiphyses documented Bone age study or X-rays
Specialist Care Pediatric endocrinologist or geneticist Provider credentials and referral
Baseline Data Growth velocity measurements Height/weight charts over time

Your partnership with your healthcare provider is crucial. They'll need to document not just the diagnosis, but also why Voxzogo is medically necessary now, before your child's growth plates close. The medication works by targeting overactive FGFR3 signaling that causes achondroplasia, but it's only effective while bones are still growing.

Note: Blue Cross Blue Shield plans in Washington typically provide 12-month initial authorizations, requiring annual reauthorization with evidence of continued growth response and open epiphyses.

Visit Prep: Gathering Your Medical History

Before your appointment, create a comprehensive timeline that demonstrates your child's need for Voxzogo. This preparation will help your provider write a stronger medical necessity letter.

Symptom and Growth Timeline

Document your child's growth pattern and any related complications:

  • Height measurements from birth to present (ask for copies from all pediatric visits)
  • Growth velocity compared to typical achondroplasia patterns
  • Functional limitations affecting daily activities or quality of life
  • Previous interventions like physical therapy or orthopedic consultations

Treatments Tried and Outcomes

While there are no FDA-approved alternatives to Voxzogo for achondroplasia, document any supportive care:

  • Growth hormone therapy (if attempted and why it was insufficient)
  • Orthopedic interventions or consultations about limb-lengthening surgery
  • Physical therapy for mobility or strength issues
  • Any complications from achondroplasia (sleep apnea, spinal stenosis, etc.)

Family Impact Documentation

Insurance companies increasingly consider quality of life factors:

  • School accommodations needed due to short stature
  • Social or psychological impacts documented by healthcare providers
  • Family's concerns about future complications without treatment

Evidence Kit: Clinical Documentation

Your provider will need specific clinical evidence to support the prior authorization request. Help them gather these essential documents.

Genetic Testing Results

The most critical piece is documented FGFR3 pathogenic variant confirming achondroplasia diagnosis. This genetic testing report must specifically identify the mutation causing achondroplasia, not just clinical features.

Growth Plate Status

Open epiphyses documentation is required for all approvals. This typically involves:

  • Bone age study showing growth plates remain open
  • Recent X-rays of long bones (usually within 6 months)
  • Radiologist's report confirming continued growth potential

Specialist Involvement

Blue Cross Blue Shield requires care from appropriate specialists:

  • Pediatric endocrinologist with experience in growth disorders, or
  • Clinical geneticist specializing in skeletal dysplasias
  • Provider's credentials and experience with achondroplasia patients

Baseline Growth Data

Comprehensive growth documentation should include:

  • Growth charts specific to achondroplasia (available at achondroplasia-growthcharts.com)
  • Annualized growth velocity calculations
  • Comparison to expected growth patterns without treatment
Clinician Corner: Medical Necessity Checklist

Essential elements for your medical necessity letter:Problem Statement: Confirmed achondroplasia with FGFR3 variant (include specific mutation)Clinical Rationale: Open growth plates with potential for improved growth velocityTreatment Goals: Increase annualized growth velocity while growth plates remain openMonitoring Plan: Regular height measurements, growth velocity tracking, periodic growth plate assessmentReferences: FDA label for Voxzogo, relevant clinical studies, achondroplasia management guidelines

Medical Necessity Letter Structure

A well-structured medical necessity letter significantly improves approval chances. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by identifying specific denial reasons and crafting point-by-point rebuttals aligned with each plan's criteria.

Essential Letter Components

Patient Demographics and Diagnosis

  • Full name, date of birth, member ID
  • ICD-10 code Q77.4 (achondroplasia)
  • Specific FGFR3 pathogenic variant from genetic testing

Clinical Justification

  • Current height and growth velocity data
  • Documentation of open epiphyses with recent imaging
  • Explanation of why treatment is medically necessary now

Treatment Plan

  • Weight-based dosing calculation (0.24 mg/kg daily subcutaneous)
  • Monitoring schedule for growth response
  • Plan for annual reauthorization requirements

Supporting Evidence

  • FDA approval for achondroplasia in pediatric patients ≥2 years
  • Clinical study data showing improved growth velocity
  • Specialist recommendation and ongoing care plan

Sample Medical Necessity Phrase

"I am writing to request prior authorization for Voxzogo (vosoritide) for [Patient Name], a [age]-year-old with genetically confirmed achondroplasia (FGFR3 pathogenic variant [specify mutation], ICD-10 Q77.4). Recent bone age studies confirm open growth plates, and the patient is under the care of a pediatric endocrinologist with expertise in skeletal dysplasias. Voxzogo is FDA-approved and medically necessary to optimize growth potential before epiphyseal closure."

Peer-to-Peer Support Strategy

If your initial prior authorization is denied, your provider can request a peer-to-peer review with a Blue Cross Blue Shield medical director. This conversation often resolves denials when the reviewing physician understands the specific clinical situation.

Preparing for Peer-to-Peer Review

Offer Availability Windows Help your provider by finding out their preferred times for these calls and communicating flexibility to Blue Cross Blue Shield.

Concise Case Summary Prepare a one-page summary highlighting:

  • Patient age and confirmed achondroplasia diagnosis
  • Current growth velocity and functional limitations
  • Open growth plates with growth potential
  • Specialist recommendation and monitoring plan

Key Talking Points

  • Voxzogo is the only FDA-approved therapy for achondroplasia
  • Treatment is time-sensitive (only effective with open growth plates)
  • Clinical studies demonstrate significant improvement in growth velocity
  • No alternative therapies available for this rare condition

After-Visit Documentation

Proper documentation after your appointment ensures continuity and supports any necessary appeals.

What to Save

  • Copy of the prior authorization submission
  • All supporting documents (genetic testing, imaging, growth charts)
  • Provider's medical necessity letter
  • Any correspondence with Blue Cross Blue Shield

Portal Messaging

Use your provider's patient portal to:

  • Confirm prior authorization was submitted
  • Request copies of all documentation
  • Ask for updates on approval status
  • Report any changes in your child's condition

Follow-Up Timeline

  • Week 1: Confirm submission and get tracking information
  • Week 2-3: Check status if no response (Blue Cross Blue Shield typically responds within 14 business days)
  • Week 4+: Initiate appeal process if denied

Respectful Persistence and Follow-Up

Insurance approvals for rare disease medications often require persistent but professional follow-up.

Appropriate Follow-Up Cadence

Weekly Check-ins: Call Blue Cross Blue Shield member services weekly after the initial 14-day review period to check status.

Provider Communication: Message your provider's office every 10-14 days for updates on their end.

Documentation: Keep a log of all calls, reference numbers, and representative names.

How to Escalate Politely

If you encounter delays or unhelpful responses:

  1. Ask for a supervisor during member services calls
  2. Request expedited review if your child's condition could worsen with delay
  3. Contact your employer's benefits administrator if you have employer-sponsored coverage
  4. File a complaint with Washington State Office of the Insurance Commissioner if needed

Blue Cross Blue Shield Washington Appeal Process

Washington state provides strong consumer protections for insurance appeals, including access to Independent Review Organizations (IROs) that can override insurer decisions.

Internal Appeal Process

Timeline: You have 180 days from the denial notice to file an internal appeal with Blue Cross Blue Shield.

Required Information:

  • Member name and ID number
  • Provider name and contact information
  • Date(s) of service or prescription
  • Copy of the original denial letter
  • Additional medical records supporting medical necessity

Submission: Contact Blue Cross Blue Shield member services or submit through their online portal (verify current submission method with your plan).

External Review Process

If your internal appeal is unsuccessful, Washington's external review process provides an independent evaluation.

Independent Review Organizations (IROs): Washington maintains a registry of certified IROs that review appeals impartially. The IRO decision is binding on your insurer.

How to Request: The denial letter from your internal appeal should explain how to request external review. You can also contact the Washington State Office of the Insurance Commissioner at 1-800-562-6900 for guidance.

Timeline: You have 180 days from the final internal denial to request external review. Standard reviews are completed within 30 days; expedited reviews within 72 hours for urgent cases.

Success Factors: External reviews often succeed for rare disease medications when:

  • Medical necessity is clearly documented
  • No FDA-approved alternatives exist
  • Treatment is time-sensitive (like Voxzogo before growth plate closure)
  • Specialist strongly supports the therapy
From Our Advocates

We've seen families successfully overturn Voxzogo denials by emphasizing the time-sensitive nature of treatment. One key strategy is highlighting that achondroplasia treatment windows are limited—once growth plates close, the opportunity for improved growth is lost forever. This urgency, combined with thorough documentation of open epiphyses and specialist support, often resonates with IRO reviewers who understand the irreversible nature of missed treatment opportunities.

BioMarin RareConnections Support

BioMarin offers comprehensive support through their RareConnections program, which has achieved a 97% success rate in securing coverage for insured Voxzogo patients.

Coverage Support Services

Dedicated Case Managers provide personalized assistance with:

  • Insurance navigation and prior authorization support
  • Documentation requirements and payer-specific checklists
  • Appeal assistance if initial requests are denied
  • Coordination with specialty pharmacies

Contact Information: Call 1-833-869-9646 (Monday-Friday, 8 AM to 8 PM PT) to connect with a Case Manager.

Financial Assistance

Co-Pay Assistance Program: Available for eligible patients with commercial insurance coverage. The program may significantly reduce out-of-pocket costs.

Eligibility Requirements:

  • Valid prescription for FDA-approved indication
  • Commercial prescription insurance coverage
  • Not valid for government-funded programs (Medicare, Medicaid, VA, TRICARE)

Program Contact: 1-866-906-6100 for co-pay assistance inquiries.

When dealing with complex rare disease coverage, platforms like Counterforce Health can help patients and providers navigate the appeals process by creating targeted, evidence-backed responses to specific denial reasons. Their approach involves analyzing the exact basis for denial—whether PA criteria, step therapy, or "not medically necessary" determinations—and crafting point-by-point rebuttals using the insurer's own policies.

Frequently Asked Questions

How long does Blue Cross Blue Shield prior authorization take in Washington? Most Blue Cross Blue Shield plans in Washington respond to prior authorization requests within 14 business days. Expedited reviews for urgent cases are typically completed within 72 hours.

What if Voxzogo is not on my Blue Cross Blue Shield formulary? Even if Voxzogo is not on your plan's formulary, you can request a formulary exception. Since there are no FDA-approved alternatives for achondroplasia, medical necessity arguments are often successful.

Can I request an expedited appeal if my child's growth plates are closing? Yes, Washington allows expedited appeals when delays could seriously impact health outcomes. Document the urgency with recent bone age studies and specialist recommendations.

Does step therapy apply to Voxzogo in Washington? Step therapy requirements vary by Blue Cross Blue Shield plan. Since no other FDA-approved therapies exist for achondroplasia, step therapy exceptions are typically granted with proper documentation.

What happens if I move to another state during treatment? Contact both your current Blue Cross Blue Shield plan and your new plan immediately. BioMarin RareConnections Case Managers can help coordinate coverage transitions to avoid treatment interruptions.

How much does Voxzogo cost without insurance? List prices are approximately $10,700 monthly for typical dosing, with annual costs around $320,000 before rebates. Actual costs vary based on weight and payer contracts.

Can adults with achondroplasia get Voxzogo covered? No, FDA approval is limited to pediatric patients with open growth plates. Coverage is not available for adults or children with closed epiphyses.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for specific coverage requirements and medical decisions. Coverage policies may vary between Blue Cross Blue Shield plans and change over time.

For personalized assistance with insurance appeals and coverage challenges, Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals tailored to each plan's specific requirements.

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