By Counterforce Health Team in Crysvita (burosumab) —

How to Get Crysvita (Burosumab) Covered by Aetna CVS Health in Texas: PA Requirements, Appeals, and Cost Support

Answer Box: Getting Crysvita Covered by Aetna CVS Health in Texas

Crysvita (burosumab) requires prior authorization from Aetna CVS Health in Texas. The fastest path: (1) Your doctor submits genetic/lab evidence of XLH or TIO diagnosis plus Aetna's precertification form, (2) Aetna reviews within 30-45 days, (3) If denied, file internal appeal within 180 days. Start today: Call your specialist to confirm diagnosis documentation and request they begin the PA process via Aetna's specialty line at (866) 752-7021.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. What Drives Crysvita's High Cost
  4. Benefit Investigation: What to Ask
  5. Cost Assistance Options
  6. Common Denial Reasons & How to Fix Them
  7. Appeals Process in Texas
  8. Specialty Pharmacy Requirements
  9. Annual Renewal Planning
  10. FAQ

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required Must be approved before dispensing Aetna Precertification List
Specialty Tier Higher copay/coinsurance than standard drugs Your plan's formulary document
Genetic/Lab Evidence PHEX mutation OR elevated FGF23 required for XLH Aetna Clinical Policy
Age Restriction Must be at least 6 months old Aetna Clinical Policy
No Concurrent Use Cannot use with oral phosphate or active vitamin D FDA Prescribing Information
Specialty Pharmacy Only Must be dispensed through designated specialty pharmacy CVS Specialty Pharmacy

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis Documentation

Who: Your endocrinologist or metabolic bone specialist
What: Genetic test showing PHEX mutation OR lab results showing elevated FGF23
Timeline: May take 2-4 weeks if testing needed
Source: Aetna requires biochemical or genetic confirmation

2. Gather Required Clinical Evidence

Who: Your care team
What: Radiographic evidence of rickets/bone disease, serum phosphorus levels, treatment history
Timeline: 1-2 weeks to compile records
Source: Aetna Clinical Policy Bulletin

3. Submit Prior Authorization Request

Who: Your prescribing physician
What: Complete Aetna's Crysvita precertification form
How: Fax to (866) 249-6155 or call (866) 752-7021
Timeline: Standard review takes 30-45 days

4. Monitor Authorization Status

Who: You and your care team
What: Follow up on pending requests
How: Call Aetna member services or check provider portal
Timeline: Weekly check-ins recommended

5. If Approved: Coordinate Specialty Pharmacy

Who: Your clinic and CVS Specialty
What: Schedule medication shipment and administration
Timeline: 1-2 weeks for first shipment
Source: Crysvita must be administered by healthcare provider

6. If Denied: File Internal Appeal Immediately

Who: You or your physician
What: Submit appeal with additional clinical documentation
Timeline: Must file within 180 days in Texas
How: Use Aetna's appeals process detailed below

7. Consider External Review if Needed

Who: You (after internal appeal denial)
What: Request Independent Review Organization (IRO) review
Timeline: Up to 4 months from final denial to file
Source: Texas Department of Insurance IRO process

What Drives Crysvita's High Cost

Crysvita's annual cost can exceed $300,000, making it one of the most expensive medications covered by insurance. Several factors contribute to this:

Specialty Drug Classification: Aetna places Crysvita on its highest formulary tier, typically requiring 20-40% coinsurance rather than a flat copay. For a $300,000 annual cost, your out-of-pocket could reach $60,000-120,000 without assistance.

Limited Competition: As the only FDA-approved FGF23 inhibitor, Crysvita has no generic or biosimilar alternatives, giving the manufacturer significant pricing power.

Complex Administration: The medication requires specialty pharmacy handling, cold storage, and healthcare provider administration, adding operational costs that insurers pass through to patients.

From Our Advocates: We've seen families initially quoted $8,000+ monthly copays for Crysvita, only to discover manufacturer assistance and appeals could reduce their costs to under $50 per month. The key is never accepting the first cost estimate without exploring all options.

Benefit Investigation: What to Ask

Before starting the authorization process, gather this information from Aetna:

Call Member Services: 1-800-872-3862
Have Ready: Your member ID, Crysvita NDC (69794-0203-01), and HCPCS code J0584

Key Questions to Ask:

  • "Is prior authorization required for Crysvita under my specific plan?"
  • "What's my specialty drug coinsurance percentage?"
  • "Do I have an annual out-of-pocket maximum that applies to specialty drugs?"
  • "Is step therapy required before Crysvita?"
  • "Which specialty pharmacy must I use?"
  • "Are there quantity limits per month?"

Information to Record:

  • Reference number for your call
  • Name of representative you spoke with
  • Exact coverage details provided
  • Any forms or documentation mentioned

Cost Assistance Options

Manufacturer Support: Kyowa Kirin Cares

For Commercial Insurance: Copay assistance can reduce your out-of-pocket to as low as $5-50 per month for eligible patients.
For Uninsured/Underinsured: Free drug program provides Crysvita at no cost to qualifying patients.
Contact: 833-KK-CARES (833-552-2737)
Eligibility: U.S. residents with commercial insurance (government insurance excluded by federal law)

Case Management Support

Kyowa Kirin Cares provides dedicated case managers who can:

  • Navigate insurance prior authorization requirements
  • Coordinate with your specialty pharmacy
  • Assist with appeal documentation
  • Connect you with financial counselors

Important: Patients on Medicare, Medicaid, TRICARE, or other government insurance cannot use manufacturer copay assistance but may receive help with coverage navigation and other support services.

At Counterforce Health, we help patients and clinicians turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned to each payer's specific requirements, potentially saving families thousands in out-of-pocket costs for specialty medications like Crysvita.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Diagnosis not confirmed" Provide genetic testing or elevated FGF23 levels PHEX gene mutation report or FGF23 lab results
"Not medically necessary" Submit clinical evidence of bone disease X-rays showing rickets, bone deformities, or osteomalacia
"Used with contraindicated medications" Confirm no concurrent phosphate/vitamin D use Provider attestation form stating no concurrent therapy
"Alternative treatments not tried" Document failure/intolerance of conventional therapy Chart notes showing inadequate response to phosphate/calcitriol
"Quantity exceeds limits" Justify weight-based dosing per FDA label Height/weight documentation and dosing calculations
"Experimental/investigational" Cite FDA approval for XLH/TIO FDA approval letter and prescribing information

Appeals Process in Texas

Internal Appeal (First Level)

Deadline: 180 days from denial notice
How to File: Call 1-800-872-3862 or submit written appeal
Timeline: 30 days for pre-service requests, 60 days for post-service
Required: Copy of denial letter, additional clinical documentation, physician letter of medical necessity

Expedited Internal Appeal

When to Use: Delay would seriously jeopardize your health
Timeline: 72 hours for decision
How: Clearly state "expedited appeal" and explain urgency

External Review (Independent Review Organization)

When: After internal appeal denial
Deadline: 4 months from final internal denial
Cost: Free (insurer pays IRO fees)
Timeline: 20 days for standard, 5 days for urgent cases
Contact: Texas Department of Insurance at 1-800-252-3439

Note: ERISA self-funded employer plans follow federal appeal rules and may have different timelines and processes than Texas state-regulated plans.

Specialty Pharmacy Requirements

Aetna requires Crysvita to be dispensed through designated specialty pharmacies, typically CVS Specialty Pharmacy for CVS Health plans.

Key Requirements:

  • No retail pharmacy dispensing - must use specialty mail-order
  • Provider administration only - cannot be self-injected at home
  • Coordinated shipment - medication ships to provider's office for your appointment
  • Temperature monitoring - requires cold storage and handling

Coordination Tips:

  1. Schedule in advance: Coordinate your appointment with medication shipment timing
  2. Confirm delivery: Verify your provider received the medication before your visit
  3. Monitor refills: Specialty pharmacy will contact you 7-10 days before next dose due
  4. Have backup plans: Know what to do if shipment is delayed or damaged

Annual Renewal Planning

What Can Change Each Year:

  • Formulary placement - Crysvita could move to a different tier
  • Prior authorization requirements - criteria may become more or less strict
  • Copay assistance limits - manufacturer programs reset annually
  • Specialty pharmacy network - your designated pharmacy could change

Renewal Checklist (December each year):

  • Review next year's formulary for Crysvita placement
  • Re-enroll in Kyowa Kirin Cares if using copay assistance
  • Confirm your specialist is still in-network
  • Update any changed contact information with all parties
  • Schedule early January appointment to avoid gaps in therapy

FAQ

How long does Aetna prior authorization take for Crysvita in Texas?
Standard review takes 30-45 days. Expedited reviews (when delay would jeopardize health) are completed within 72 hours. Source: Aetna policy timelines

What if Crysvita is not on my Aetna formulary?
You can request a formulary exception by submitting clinical documentation showing medical necessity and that formulary alternatives are inappropriate. Use the same prior authorization process.

Can I request an expedited appeal in Texas?
Yes, if delay would seriously jeopardize your health. Both internal appeals (72 hours) and external reviews (5 days) have expedited options available.

Does step therapy apply to Crysvita?
Aetna may require documentation that conventional treatments (phosphate and active vitamin D) were tried and failed or are contraindicated before approving Crysvita.

What happens if I move from Texas to another state?
Appeal rights and timelines may change depending on your new state's insurance regulations. Contact your plan immediately to understand any differences.

Can my doctor do a peer-to-peer review?
Yes, physicians can request to speak directly with Aetna's medical director about denied cases. This is often effective for complex rare disease cases like XLH.

How do I find Texas-specific help with my appeal?
Contact the Texas Department of Insurance at 1-800-252-3439 or the Office of Public Insurance Counsel at 1-877-611-6742 for free assistance with insurance disputes.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage and appeal processes can vary by specific plan and individual circumstances. Always consult with your healthcare provider and insurance plan directly for guidance specific to your situation. For additional support with complex prior authorization and appeal processes, Counterforce Health provides specialized assistance to help patients and clinicians navigate insurance denials for specialty medications.

Last updated: Based on 2024 Aetna policies and Texas insurance regulations. Verify current requirements with your specific plan.

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