By Counterforce Health Team in Crysvita (burosumab) —

How to Get Crysvita (Burosumab) Covered by Aetna CVS Health in Florida: Complete PA Guide with Appeals Timeline

Answer Box: Getting Crysvita Approved by Aetna CVS Health in Florida

Crysvita (burosumab) requires prior authorization from Aetna CVS Health. Your fastest path to approval: Submit the Aetna Crysvita precertification form with genetic testing (PHEX mutation) or elevated FGF23 levels, plus radiographic evidence of bone disease. First step today: Call your prescriber to gather diagnostic documentation and submit via CVS Caremark at (866) 752-7021. Standard review takes 30-45 days. If denied, Florida residents have 180 days to appeal internally, then 4 months for external review.

Table of Contents

  1. Plan Types & Coverage Implications
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Process
  5. Cost-Share Dynamics
  6. Submission Process
  7. Common Approval Patterns
  8. Appeals Process in Florida
  9. Clinician Corner: Medical Necessity
  10. FAQ

Plan Types & Coverage Implications

Aetna CVS Health operates several plan types in Florida, each with different referral and network requirements:

  • HMO plans: Require primary care physician referrals to specialists like endocrinologists
  • PPO plans: Allow direct access to specialists but offer better coverage for in-network providers
  • EPO plans: No referrals needed but strictly in-network coverage only
  • Medicare Advantage: Follow Medicare Part B and Part D guidelines with additional Aetna requirements

For Crysvita, all plan types require prior authorization regardless of whether you see an in-network endocrinologist or metabolic bone disease specialist.

Formulary Status & Tier Placement

Crysvita is classified as a specialty tier, non-formulary medication on most Aetna plans. This means:

  • Not automatically covered without meeting specific clinical criteria
  • Higher cost-sharing compared to preferred medications
  • Specialty pharmacy dispensing required through CVS Specialty
  • No generic alternatives available (burosumab is a biologic)

Coverage at a Glance

Requirement What it means Where to find it Source
PA needed? Yes, all requests Aetna Precert List Official
Formulary tier Specialty, non-formulary Plan drug guide Member portal
Step therapy May apply (verify with plan) Clinical policy Policy bulletin
Age limits 6 months or older FDA label FDA
Site of care Outpatient/home injection Provider discretion Clinical judgment

Prior Authorization Requirements

Aetna requires specific diagnostic confirmation for both approved indications:

For X-linked Hypophosphatemia (XLH)

Required documentation:

  • Genetic test confirming PHEX gene mutation in patient OR family member with X-linked inheritance
  • OR elevated FGF23 level above normal range
  • Radiographic evidence of rickets or bone disease attributed to XLH
  • Patient age 6 months or older
  • Prescriber experienced in metabolic bone disease

For Tumor-Induced Osteomalacia (TIO)

Required documentation:

  • FGF23 level above normal range
  • Fasting serum phosphorus < 2.5 mg/dL
  • TmP/GFR ratio < 2.5 mg/dL
  • Disease associated with phosphaturic mesenchymal tumors that cannot be resected

Critical requirement for both indications: Provider attestation that Crysvita will not be used concurrently with oral phosphate supplements or active vitamin D.

Specialty Pharmacy Process

Crysvita must be dispensed through CVS Specialty or another Aetna-approved specialty pharmacy. Here's the patient setup process:

  1. Prescription routing: Your doctor submits the prescription directly to CVS Specialty
  2. Patient enrollment: CVS Specialty contacts you to verify insurance and shipping preferences
  3. Coordination of benefits: They handle prior authorization submission and follow-up
  4. Delivery scheduling: Medication ships with temperature monitoring for subcutaneous injection
  5. Ongoing support: CVS Specialty provides injection training and refill coordination

Contact CVS Specialty directly at their main line (verify current number with your plan) for status updates.

Cost-Share Dynamics

Understanding your out-of-pocket costs helps with financial planning:

  • Specialty tier copay/coinsurance: Typically 25-50% of drug cost after deductible
  • Annual out-of-pocket maximum: Provides cost protection once reached
  • Deductible application: Most plans apply specialty drugs to medical or pharmacy deductible

Cost-saving options to explore:

  • Manufacturer copay assistance programs
  • Patient foundation grants for rare diseases
  • State pharmaceutical assistance programs in Florida

Note: This is educational information only. Consult your plan documents for specific cost-sharing details.

Submission Process

Step-by-Step: Fastest Path to Approval

  1. Gather diagnostic evidence (Patient/Clinic): Collect genetic testing results or FGF23 lab values, plus bone imaging
    • Timeline: 1-2 weeks if tests already completed
    • Document needed: Lab reports, genetic testing, X-rays/DEXA scans
  2. Complete Aetna precertification form (Clinic): Download and fill out the official Crysvita form
    • Timeline: 1-2 business days
    • Critical fields: All sections must be complete and legible
  3. Submit via CVS Caremark (Clinic): Call (866) 752-7021 or fax (888) 267-3277
    • Timeline: Same day submission possible
    • Follow-up: Request confirmation number
  4. Track review status (Patient/Clinic): Monitor for requests for additional information
    • Timeline: Standard review 30-45 days
    • Expedited option: Available for urgent medical situations
  5. Receive determination (Patient): Approval letter includes specialty pharmacy setup instructions
    • If approved: CVS Specialty contacts you within 24-48 hours
    • If denied: Review denial letter for specific reasons and appeal rights

Counterforce Health helps patients and clinicians navigate complex prior authorization requirements by analyzing denial letters and creating evidence-backed appeals that address payer-specific criteria. Their platform identifies exactly why coverage was denied and builds targeted rebuttals using the right clinical evidence and policy language.

Common Approval Patterns

Strong submissions typically include:

Clinical documentation:

  • Clear diagnosis with appropriate ICD-10 codes (E83.31 for XLH)
  • Baseline serum phosphorus, alkaline phosphatase, and vitamin D levels
  • Documentation of bone disease impact on daily functioning
  • Treatment goals and monitoring plan

Provider qualifications:

  • Endocrinologist, nephrologist, or metabolic bone disease specialist
  • Statement of experience with rare phosphate disorders
  • Plan for ongoing monitoring and dose adjustments

Policy alignment:

  • Explicit confirmation of no concurrent oral phosphate/active vitamin D use
  • Age verification (6 months or older)
  • Appropriate dosing per FDA label (1 mg/kg every 4 weeks, max 90 mg)

Appeals Process in Florida

Florida residents have well-defined appeal rights when Aetna denies Crysvita coverage:

Internal Appeals Timeline

  • Deadline to file: 180 days from denial notice
  • Aetna review period: 30 days for standard appeals, 72 hours for urgent
  • Required documents: Denial letter, additional clinical evidence, prescriber letter

External Review Process

If internal appeals fail, Florida offers independent external review:

  • Eligibility: Must complete internal appeals first (unless urgent)
  • Deadline: 4 months after final internal denial
  • Process: Florida Department of Financial Services coordinates with independent medical reviewers
  • Timeline: 30 days standard, 72 hours expedited
  • Cost: No charge to patient
  • Decision: Binding on Aetna

Florida Consumer Assistance: Call the Insurance Consumer Helpline at (877) 693-5236 for help navigating the appeals process.

Clinician Corner: Medical Necessity

Medical Necessity Letter Checklist

When writing appeals or initial authorization letters, include:

Problem statement:

  • Specific diagnosis (XLH or TIO) with supporting evidence
  • Current symptoms and functional limitations
  • Impact on quality of life and daily activities

Prior treatments:

  • Previous therapies tried (if any) and outcomes
  • Contraindications to conventional phosphate/vitamin D therapy
  • Reasons why alternatives are inappropriate

Clinical rationale:

  • Why Crysvita is medically necessary for this patient
  • Expected treatment outcomes and monitoring plan
  • Alignment with FDA-approved indications

Monitoring plan:

  • Serum phosphorus monitoring every 2 weeks initially, then monthly
  • Renal function and calcium level tracking
  • Clinical response assessment timeline
From our advocates: We've seen the strongest approvals when clinicians explicitly address Aetna's policy requirements in their letters—particularly the attestation about not using concurrent oral phosphate or active vitamin D. Including specific lab values and referencing the FDA label's monitoring recommendations also strengthens the case significantly.

FAQ

How long does Aetna CVS Health prior authorization take in Florida? Standard reviews take 30-45 days. Expedited reviews for urgent medical situations can be completed within 72 hours when properly documented.

What if Crysvita is non-formulary on my plan? Non-formulary status means prior authorization is required, but coverage is possible when medical necessity criteria are met. The appeals process can also address formulary exceptions.

Can I request an expedited appeal in Florida? Yes, if your doctor certifies that delays could jeopardize your health. Both internal and external expedited appeals are available with 72-hour timelines.

Does step therapy apply if I've tried treatments outside Florida? Prior treatment history from other states should be accepted as long as it's properly documented. Include all medical records when submitting your authorization request.

What happens if I'm already on Crysvita and switch to Aetna? You may need a new prior authorization even if you were previously approved by another insurer. Start the process immediately to avoid treatment interruptions.

How do I find an Aetna-approved specialty pharmacy in Florida? CVS Specialty is the primary option, but other approved pharmacies may be available. Check your plan documents or call member services to confirm your options.

What if my doctor isn't experienced with rare bone diseases? Aetna requires prescribers to have experience with metabolic bone disease. Consider getting a consultation or co-management arrangement with an endocrinologist or specialist.

Can I appeal to Florida state regulators if Aetna denies coverage? Yes, after exhausting internal appeals, you can request external review through the Florida Department of Financial Services, which uses independent medical reviewers to make binding decisions.

When facing complex prior authorization requirements, Counterforce Health provides specialized support by analyzing your specific denial and creating targeted appeals that address each of Aetna's policy requirements with the right clinical evidence and documentation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may change. Always consult your specific plan documents, healthcare providers, and Aetna directly for the most current information regarding your coverage and treatment options.

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