By Counterforce Health Team in Voxzogo (vosoritide) —

Getting Voxzogo (Vosoritide) Approved by UnitedHealthcare in Illinois: Complete ICD-10, HCPCS, and Appeal Guide

Answer Box: Getting Voxzogo Covered by UnitedHealthcare in Illinois

UnitedHealthcare requires prior authorization for Voxzogo (vosoritide) in Illinois with specific documentation: confirmed achondroplasia diagnosis (ICD-10 Q77.4), open epiphyses via X-ray, patient under 18, and specialist prescription. Submit via OptumRx provider portal with complete clinical records. If denied, you have 60 days to appeal internally, then 30 days for Illinois external review through the Department of Insurance. Start today: Verify your plan's formulary status and gather growth charts, genetic testing results, and bone age imaging.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 and Documentation Requirements
  3. HCPCS, J-Codes, and NDC Information
  4. Prior Authorization: Clean Request Anatomy
  5. Common Coding Pitfalls to Avoid
  6. UnitedHealthcare Verification Steps
  7. Illinois Appeals Process
  8. Pre-Submission Audit Checklist

Coding Basics: Medical vs. Pharmacy Benefit

Voxzogo (vosoritide) billing depends on where and how it's administered, affecting which codes you'll need:

Medical Benefit (Physician-Administered)

  • Use when given in clinic/office setting
  • HCPCS: J3590 (unclassified biologics)
  • CPT: 96372 (therapeutic injection, subcutaneous)
  • Reimbursement: ~$2,500-$3,500 per dose based on ASP

Pharmacy Benefit (Self-Administered)

  • Use for home injection after initiation
  • NDC: 69476-656-15 (15 mg/1.2 mL vial)
  • Covered under specialty pharmacy networks
  • Patient copay assistance available through BioMarin VOXZOGO Connect
Note: Most UnitedHealthcare plans start with medical benefit for initiation, then transition to specialty pharmacy for ongoing treatment.

ICD-10 and Documentation Requirements

Primary Diagnosis Code

ICD-10: Q77.4 - Achondroplasia

This code specifically documents achondroplasia caused by FGFR3 variants and is required for all Voxzogo prior authorization requests.

Supporting Documentation Words

When documenting achondroplasia, include these clinical terms that support the Q77.4 coding:

  • Macrocephaly with frontal bossing
  • Rhizomelic limb shortening
  • Midface retrusion
  • Disproportionate short stature
  • FGFR3 pathogenic variant (if tested)
  • Growth velocity below 3rd percentile

UnitedHealthcare Requirements

Requirement Documentation Needed Timeline
Achondroplasia Diagnosis Clinical features + genetic testing (if available) Current
Open Epiphyses X-ray or bone age imaging Within 3 months
Age Verification Patient under 18 years Current
Growth Data Height/weight charts showing poor velocity 6-12 months
Specialist Prescription Pediatric endocrinologist or geneticist Current

HCPCS, J-Codes, and NDC Information

Current Billing Codes

HCPCS J-Code: J3590

  • Temporary code for unclassified biologics
  • Used until permanent Voxzogo-specific code assigned
  • Bill per vial used, document waste if applicable

NDC Numbers:

  • Primary: 69476-656-15 (15 mg/1.2 mL)
  • Alternative: 69476-657-25 (25 mg/2 mL)
  • Alternative: 69476-658-40 (40 mg/3.2 mL)

Dosing and Units Math

Voxzogo is dosed at 0.24 mg/kg once daily subcutaneously. Calculate units based on patient weight:

  • 20 kg patient = 4.8 mg daily dose
  • Use 15 mg vial (NDC 69476-656-15)
  • Bill 1 unit per vial
  • Document 10.2 mg as allowable waste
Tip: CMS allows waste billing for single-dose vials when waste exceeds 10% of the vial contents.

Prior Authorization: Clean Request Anatomy

Here's what a complete UnitedHealthcare Voxzogo prior authorization should include:

Patient Information Section

Patient: [Name], DOB: [Date]
Member ID: [UHC ID Number]
Diagnosis: Achondroplasia (ICD-10: Q77.4)
Prescriber: [Pediatric Endocrinologist/Geneticist]

Clinical Documentation

  1. Genetic testing report showing FGFR3 pathogenic variant
  2. Growth charts (6-12 months) demonstrating poor velocity
  3. Bone age X-rays confirming open epiphyses (within 3 months)
  4. Specialist consultation notes with treatment rationale

Prescription Details

  • Drug: Voxzogo (vosoritide) 15 mg/1.2 mL
  • NDC: 69476-656-15
  • Dose: 0.24 mg/kg daily subcutaneous
  • Duration: 12 months (renewable)
  • Quantity: [Based on weight calculation]

Submission Method

Submit via OptumRx provider portal or fax to prior authorization department (verify current fax number through portal).

Common Coding Pitfalls to Avoid

Unit Conversion Errors

Wrong: Billing multiple units for partial vial use Right: Bill one unit per vial, document waste separately

Mismatched Codes

Wrong: Using growth hormone J-codes (J2941) for Voxzogo Right: Use J3590 until permanent Voxzogo code available

Missing Start Dates

Wrong: Leaving start date blank on PA request Right: Include specific start date within 30 days of submission

Documentation Gaps

Wrong: Submitting PA without genetic confirmation Right: Include FGFR3 variant report or detailed clinical description

UnitedHealthcare Verification Steps

Before submitting your Voxzogo request, verify these details through UnitedHealthcare resources:

Step 1: Check Formulary Status

  • Log into UHC Provider Portal
  • Search "Voxzogo" or NDC 69476-656-15
  • Confirm specialty tier placement and PA requirement

Step 2: Review Current PA Criteria

  • Download latest Voxzogo PA form
  • Check for any 2025 criteria updates
  • Verify required specialist credentials

Step 3: Confirm Submission Method

  • Provider portal preferred for faster processing
  • Fax backup available (verify current number)
  • Allow 15 business days standard, 72 hours expedited

Illinois Appeals Process

If UnitedHealthcare denies your Voxzogo request, Illinois provides strong patient protection through structured appeal rights.

Internal Appeal Timeline

  • Filing deadline: 60 days from denial date
  • UHC response time: 30 days (pre-service) or 60 days (post-service)
  • Expedited option: 72 hours when health is at risk

External Review Process

After internal appeal denial, Illinois residents can request independent external review:

  • Filing deadline: 30 days from final internal denial (shorter than most states)
  • Review timeline: 5 business days after IRO receives records
  • Cost: Free to patients (insurer pays IRO fees)
  • Decision: Binding on UnitedHealthcare

Illinois Resources

  • Department of Insurance: (877) 527-9431
  • Attorney General Health Care Helpline: (877) 305-5145
  • External Review Forms: Available through Illinois DOI website
From our advocates: "We've seen families succeed by documenting not just the medical need, but the urgency—when growth plates are closing, that 30-day Illinois external review deadline becomes critical. One case involved a 16-year-old where the family emphasized limited time for treatment effectiveness, and the IRO overturned the denial within days."

Pre-Submission Audit Checklist

Review these items before submitting your Voxzogo prior authorization:

Required Documentation ✓

  • Completed UnitedHealthcare PA form
  • ICD-10 Q77.4 diagnosis confirmation
  • FGFR3 genetic testing (if available)
  • Growth charts (6-12 months)
  • Bone age X-rays (within 3 months)
  • Specialist consultation notes
  • Patient under 18 years verification

Coding Accuracy ✓

  • Correct NDC: 69476-656-15
  • Appropriate HCPCS: J3590
  • Proper dosing calculation (0.24 mg/kg)
  • CPT 96372 for injections (if applicable)

Submission Details ✓

  • Provider portal access confirmed
  • All required fields completed
  • Start date within 30 days
  • Contact information current
  • Expedited request justified (if applicable)

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all plans UHC PA Policy
Age Limit Under 18 years UHC PA Criteria
Specialist Required Pediatric endocrinologist/geneticist UHC PA Criteria
Step Therapy Not required UHC Policy Review
Appeals Deadline 60 days (internal), 30 days (external) Illinois Insurance Code

Cost and Savings Options

Manufacturer Support:

  • BioMarin VOXZOGO Connect: Up to $15,000/year copay assistance
  • Phone: 1-833-VOXZOGO
  • Eligibility: Commercial insurance patients

Foundation Grants:

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Good Days (formerly Chronic Disease Fund)

FAQ

How long does UnitedHealthcare prior authorization take in Illinois? Standard review: 15 business days. Expedited review: 72 hours when medically urgent.

What if Voxzogo is non-formulary on my plan? Request formulary exception with medical necessity documentation. Illinois law requires fair review of non-formulary requests.

Can I request expedited appeal if denied? Yes, if delay would seriously jeopardize health. Particularly relevant for older adolescents with closing growth plates.

Does step therapy apply if I've failed treatments outside Illinois? UnitedHealthcare accepts out-of-state treatment history. Document prior therapy failures with medical records.

What counts as medical necessity for Voxzogo? Confirmed achondroplasia with growth velocity impairment and open epiphyses in patient under 18.

When to Escalate

Contact Illinois regulators if UnitedHealthcare:

  • Misses appeal deadlines
  • Requests inappropriate documentation
  • Denies without clear medical rationale

Illinois Department of Insurance

  • Consumer Hotline: (877) 527-9431
  • File complaints online through DOI website
  • Include all correspondence and medical records

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform ingests denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to each payer's specific rules, pulling the right citations and clinical facts to build compelling cases that reduce back-and-forth and improve approval rates.

For more complex appeals or when facing repeated denials, consider working with Counterforce Health to ensure your Voxzogo appeal includes all necessary clinical evidence and payer-specific arguments.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and clinical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For questions about Illinois insurance regulations, contact the Illinois Department of Insurance.

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