How to Get Crysvita (burosumab) Covered by Aetna (CVS Health) in Georgia: Complete PA Guide with Appeals Timeline
Answer Box: Getting Crysvita Covered by Aetna in Georgia
Fast track to approval: Aetna (CVS Health) requires prior authorization for Crysvita (burosumab) with documented XLH diagnosis, failed oral phosphate/calcitriol therapy, and specialist oversight. If denied, Georgia residents have 60 days to file an external review through the Department of Insurance. Start today: Gather genetic testing or FGF23 lab results, document prior treatment failures, and work with an endocrinologist to submit your PA request through CVS Caremark's specialty pharmacy network.
Table of Contents
- Coverage Requirements at a Glance
- Step-by-Step: Fastest Path to Approval
- Common Denial Reasons & How to Fix Them
- Appeals Playbook for Georgia Residents
- Costs & Patient Assistance Programs
- Clinician Corner: Medical Necessity Documentation
- When Your Case Gets Complex
- FAQ: Your Top Questions Answered
Coverage Requirements at a Glance
| Requirement | What It Means | Where to Find It |
|---|---|---|
| Prior Authorization | Yes, always required | CVS Caremark PA portal |
| Formulary Status | Specialty tier, non-formulary | Member portal or call member services |
| Step Therapy | Must try/fail phosphate + calcitriol | Document 3-6 month trial or contraindications |
| Prescriber | Endocrinologist or metabolic specialist | Provider network directory |
| Age Limits | 6+ months (XLH), 2+ years (TIO) | FDA labeling requirements |
| Diagnosis Codes | E83.30 (XLH), M83.8 (TIO) | ICD-10 coding manual |
| Appeals Deadline | 60 days for external review | Georgia Department of Insurance |
Step-by-Step: Fastest Path to Approval
1. Confirm Your Diagnosis (Patient + Clinic)
What you need: Genetic testing showing PHEX mutation OR elevated serum FGF23 levels plus low fasting serum phosphorus. Your endocrinologist should order these if not already done. Timeline: 1-2 weeks for lab results Submit to: Keep results for PA packet
2. Document Step Therapy Attempts (Clinic)
What you need: Records showing you tried oral phosphate supplements and calcitriol (or similar active vitamin D) for at least 3-6 months, unless contraindicated. Timeline: Gather existing records immediately Submit to: Include in PA documentation
Note: Crysvita cannot be used with oral phosphate or active vitamin D—these must be stopped before starting treatment.
3. Submit Prior Authorization (Clinic)
What you need: Complete PA form through CVS Caremark with diagnosis proof, step therapy documentation, and specialist oversight. Timeline: 30-45 days for standard review Submit to: CVS Caremark specialty pharmacy network
4. Monitor for Decision (Patient + Clinic)
What you need: Watch for approval letter or denial with specific reasons. Timeline: Check status after 30 days if no response Submit to: N/A - wait for insurer response
5. Appeal if Denied (Patient + Clinic)
What you need: Internal appeal within 180 days, then external review within 60 days if still denied. Timeline: 45 days for external review decision in Georgia Submit to: Georgia Department of Insurance ([email protected])
Common Denial Reasons & How to Fix Them
| Denial Reason | How to Overturn | Required Documentation |
|---|---|---|
| Lack of genetic confirmation | Submit PHEX gene test or elevated FGF23 | Lab reports with reference ranges |
| No step therapy documentation | Provide detailed prior treatment history | Pharmacy records, clinic notes |
| Wrong prescriber | Transfer to endocrinologist oversight | Referral documentation |
| "Experimental" designation | Reference FDA approval for XLH/TIO | FDA Orange Book listing |
| Quantity limits exceeded | Justify weight-based dosing protocol | Dosing calculations, growth charts |
Appeals Playbook for Georgia Residents
Internal Appeal with Aetna
- Deadline: 180 days from denial date
- Timeline: 30-45 days for standard review, 72 hours for urgent cases
- How to file: Aetna member portal or written request
- Required: All new supporting documentation, specialist letter
External Review in Georgia
- Deadline: 60 days from final internal denial
- Timeline: 45 days for standard review, 72 hours for urgent cases
- How to file: Georgia Department of Insurance form ([email protected])
- Cost: Free to patients (insurer pays review fees)
- Decision: Binding on Aetna—they must comply if you win
Tip: For urgent medical situations, you can request expedited external review even while your internal appeal is pending.
Success Rates
Based on state data, 30-50% of specialty drug denials are overturned on external review when proper documentation is provided.
Costs & Patient Assistance Programs
Typical Costs: Crysvita ranges from $4,000-$40,000+ per vial depending on strength, with annual costs varying by patient weight and dosing schedule.
Financial Support Options:
- Kyowa Kirin Cares: Manufacturer copay assistance and patient support services
- CVS Specialty Pharmacy: Benefit investigation and insurance coordination
- State Programs: Georgia may have additional assistance—check with the Department of Community Health
Clinician Corner: Medical Necessity Documentation
Essential Elements for Your Letter:
- Clear diagnosis: "Patient has confirmed X-linked hypophosphatemia via [genetic testing/elevated FGF23]"
- Prior failures: "Despite 6 months of oral phosphate 2g daily and calcitriol 0.5 mcg twice daily, patient continues to exhibit..."
- Clinical necessity: "Without Crysvita, patient faces progressive bone disease, fractures, and functional decline"
- Monitoring plan: "Will monitor serum phosphorus monthly and adjust dosing per protocol"
- Contraindication note: "Patient will discontinue phosphate and vitamin D analogs before starting burosumab"
Key References to Cite:
- FDA labeling for Crysvita (burosumab-twza)
- Endocrine Society clinical practice guidelines
- Patient-specific lab values and imaging studies
When Your Case Gets Complex
Sometimes standard appeals aren't enough. Here's when to escalate:
Contact Georgia Department of Insurance (1-800-656-2298) if:
- Aetna isn't following proper appeal timelines
- You're not getting clear denial reasons
- The external review process seems stalled
Consider Counterforce Health for complex cases requiring detailed evidence-backed appeals. Their platform specializes in turning insurance denials into targeted rebuttals aligned with payer policies, pulling the right citations and clinical documentation for medications like Crysvita.
Legal consultation may be warranted for cases involving:
- Repeated denials despite meeting all criteria
- Urgent medical situations with delayed care
- Potential bad faith insurance practices
FAQ: Your Top Questions Answered
Q: How long does Aetna's prior authorization take in Georgia? A: Standard PA decisions take 30-45 days. Urgent cases can be expedited to 72 hours with proper medical justification.
Q: What if Crysvita isn't on Aetna's formulary? A: You can request a formulary exception with documentation that covered alternatives are inappropriate or ineffective for your condition.
Q: Can I appeal if I tried step therapy outside Georgia? A: Yes, treatment history from any location counts as long as it's properly documented by a licensed physician.
Q: Does my child need to see a pediatric endocrinologist? A: While helpful, adult endocrinologists experienced in metabolic bone disease can also manage XLH cases. The key is specialist-level expertise.
Q: What happens if I win my external review? A: Aetna must approve coverage and pay for your treatment. The decision is legally binding under Georgia law.
Q: Can I get Crysvita through a regular pharmacy? A: No, Aetna typically requires specialty pharmacy dispensing through CVS Specialty for medications like Crysvita.
From Our Advocates
We've seen Georgia families succeed with Crysvita appeals by focusing on three key elements: comprehensive genetic or biochemical confirmation of XLH, detailed documentation of failed conventional therapies with specific doses and timeframes, and clear specialist oversight throughout the process. The external review system in Georgia is particularly effective when families provide organized medical records and emphasize the progressive nature of untreated XLH.
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for the most current requirements. Coverage policies may vary by plan type and can change without notice.
For official appeals assistance in Georgia, contact the Department of Insurance Consumer Services Division at [email protected] or 1-800-656-2298.
Getting Crysvita covered requires patience and thorough documentation, but Counterforce Health and other advocacy resources can help navigate the complex approval process. With the right preparation and persistence, many Georgia families have successfully obtained coverage for this important treatment.
Sources & Further Reading
- Georgia Department of Insurance Appeals Process
- CVS Caremark Prior Authorization Requirements
- FDA Crysvita Prescribing Information
- Kyowa Kirin Patient Support Programs
- Georgia Consumer Insurance Assistance
Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.