By Counterforce Health Team in Crysvita (burosumab) —

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

Answer Box: Your Path to Crysvita Coverage

Aetna (CVS Health) requires prior authorization for all Crysvita (burosumab) requests in Virginia. Most approvals take 30-45 days with complete documentation. Start today: (1) Have your specialist complete Aetna's Crysvita precertification form, (2) gather genetic testing or biochemical evidence of XLH/TIO, and (3) document baseline low serum phosphorus levels. If denied, Virginia offers independent external review through the State Corporation Commission within 120 days. Kyowa Kirin Cares provides case management support throughout the process.

Table of Contents

  1. Coverage Basics: Is Crysvita Covered?
  2. The Prior Authorization Process
  3. Timeline: How Long Does Approval Take?
  4. Clinical Criteria: What Documentation is Required?
  5. Cost Structure: Understanding Your Out-of-Pocket Expenses
  6. Common Denial Reasons & How to Fix Them
  7. Virginia Appeals Process: Your Rights
  8. Renewal Requirements
  9. Specialty Pharmacy Requirements
  10. Troubleshooting Common Issues
  11. Frequently Asked Questions

Coverage Basics: Is Crysvita Covered?

Yes, Aetna (CVS Health) covers Crysvita (burosumab) for FDA-approved indications, but prior authorization is mandatory for all commercial, Medicare, and Medicaid plans in Virginia.

Coverage at a Glance

Requirement What It Means Source
Prior Authorization Required for all uses 2025 Precertification List
Formulary Tier Specialty tier (20-40% coinsurance) Plan documents
Approved Indications XLH (≥6 months), TIO (≥2 years) Aetna Policy CPB 0932
Specialty Pharmacy CVS Specialty required CVS Caremark network
Prescriber Requirements Specialist recommended Policy guidelines

The Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify Benefits (Patient/Clinic)
    • Call Aetna member services to confirm PA requirements
    • Check if medical vs. pharmacy benefit applies
    • Timeline: Same day
  2. Complete Aetna's Crysvita Form (Prescriber)
  3. Submit to CVS Specialty (Clinic Staff)
    • Phone: 866-752-7021
    • Fax: 888-267-3277
    • Timeline: Same day submission
  4. Track Status (Clinic/Patient)
    • Monitor via Aetna provider portal
    • Follow up weekly until decision
    • Timeline: Ongoing during review
  5. CVS Specialty Coordination (If Approved)
    • Specialty pharmacy will contact patient
    • Schedule delivery and administration
    • Timeline: 1-2 weeks post-approval
Tip: Enroll in Kyowa Kirin Cares for dedicated case management support throughout the PA process.

Timeline: How Long Does Approval Take?

Based on Aetna's published guidelines:

  • Standard Review: 30-45 days after complete submission
  • Expedited Review: 72 hours (requires physician certification of urgency)
  • Incomplete Submissions: Additional 15-30 days for missing documentation

When to Request Expedited Review

Request expedited processing if delay would:

  • Worsen bone deformities or fractures
  • Cause significant pain or mobility loss
  • Impact a child's growth trajectory
  • Lead to hospitalization or emergency care

Clinical Criteria: What Documentation is Required?

For X-Linked Hypophosphatemia (XLH)

Diagnostic Evidence Required:

  • Genetic confirmation: PHEX mutation testing results, OR
  • Clinical diagnosis: Family history plus compatible phenotype
  • Biochemical evidence: Multiple fasting serum phosphorus levels below normal range
  • Radiographic evidence: X-rays showing rickets, osteomalacia, or skeletal deformities

Additional Requirements:

  • Age ≥6 months
  • Documentation of inadequate response to conventional therapy (oral phosphate/active vitamin D)
  • Current weight for dosing calculations
  • Specialist evaluation (endocrinology, nephrology, or metabolic bone disease)

For Tumor-Induced Osteomalacia (TIO)

Required Documentation:

  • Imaging confirmation of mesenchymal tumor
  • Documentation that tumor cannot be curatively resected
  • Biochemical evidence of FGF23-mediated hypophosphatemia
  • Age ≥2 years

Clinician Corner: Medical Necessity Letter Checklist

Your letter should address:

✓ Problem Statement: Specific diagnosis (XLH or TIO) with ICD-10 code
✓ Clinical History: Symptoms, functional limitations, fracture history
✓ Prior Treatments: Oral phosphate/calcitriol trials and outcomes
✓ Current Status: Recent labs, imaging, growth parameters
✓ Treatment Plan: Weight-based dosing schedule, monitoring plan
✓ Guidelines: Reference to FDA labeling and specialist society recommendations

Cost Structure: Understanding Your Out-of-Pocket Expenses

Typical Cost-Sharing

  • Specialty Tier: 20-40% coinsurance (no fixed copay)
  • Annual Cost: $300,000+ for Crysvita treatment
  • Patient Responsibility: $60,000-$120,000 annually without assistance

Cost Support Options

  1. Kyowa Kirin Cares: Copay assistance for eligible commercial patients
  2. Foundation Grants: Various rare disease foundations offer support
  3. Virginia Medicaid: May have lower cost-sharing for eligible patients

Common Denial Reasons & How to Fix Them

Denial Reason How to Fix It Required Documents
"Insufficient diagnostic evidence" Submit genetic testing or detailed clinical assessment PHEX mutation results or specialist evaluation
"No documented hypophosphatemia" Provide baseline labs Multiple fasting serum phosphorus levels
"Experimental/investigational" Cite FDA approval and policy coverage Reference CPB 0932 and FDA labeling
"Age restriction" Confirm patient meets minimum age Birth certificate or medical records
"Incomplete form" Resubmit with all required fields Complete precertification form
"Wrong prescriber type" Have specialist co-sign or refer Endocrinologist/nephrologist evaluation

Script for Peer-to-Peer Review Request

"This is Dr. [Name] requesting a peer-to-peer review for [Patient Name] regarding Crysvita coverage. The patient has confirmed XLH with [genetic/clinical evidence] and documented hypophosphatemia. This is an FDA-approved indication covered under your policy CPB 0932. When can we schedule the clinical discussion?"

Virginia Appeals Process: Your Rights

Virginia law provides strong protections for patients facing coverage denials. Here's your complete appeals roadmap:

Internal Appeals with Aetna

Level 1 Internal Appeal

  • Deadline: File within 180 days of denial
  • Decision Timeline: 30 days (standard) or 72 hours (expedited)
  • How to File: Written request with supporting documentation

Required Appeal Documents:

  • Copy of denial letter
  • Updated medical necessity letter
  • All clinical documentation (labs, imaging, notes)
  • Patient impact statement

Virginia External Review

After exhausting Aetna's internal appeals, Virginia offers independent external review through the State Corporation Commission.

Key Details:

  • Filing Deadline: 120 days from final internal denial
  • Cost: Free to Virginia residents
  • Decision Timeline: 45 days (standard) or 72 hours (expedited)
  • Binding: Decision is final and binding on Aetna

How to File:

  1. Complete Virginia SCC Form 216-A
  2. Attach all denial letters and clinical documentation
  3. Submit to Virginia State Corporation Commission, Bureau of Insurance
  4. Contact: 1-877-310-6560 for guidance
Note: Virginia's Managed Care Ombudsman can provide free assistance navigating the appeals process.

When to Escalate to External Review

Consider external review if Aetna denied based on:

  • Medical necessity determination
  • Experimental/investigational classification
  • Clinical judgment issues
  • Policy interpretation disputes

Renewal Requirements

Crysvita reauthorization typically occurs annually and requires evidence of clinical benefit:

Required Documentation:

  • Follow-up labs: Improved or normalized serum phosphate levels
  • Clinical response: Reduced bone pain, fewer fractures, improved growth
  • Adherence: Documentation of consistent treatment
  • Ongoing monitoring: Regular specialist follow-up

Renewal Timeline: Submit 30-60 days before current authorization expires to avoid treatment interruption.

Specialty Pharmacy Requirements

Why CVS Specialty? Aetna requires Crysvita to be dispensed through CVS Specialty Pharmacy due to:

  • Temperature-controlled storage requirements
  • Administration training needs
  • Specialized handling protocols
  • Insurance coordination requirements

What to Expect:

  • Initial consultation with specialty pharmacist
  • Delivery coordination to clinic or home
  • Administration supplies and training
  • Ongoing refill management

Troubleshooting Common Issues

Portal Access Problems

  • Issue: Can't access Aetna provider portal
  • Solution: Contact provider services at 1-800-624-0756

Missing Forms

Delayed Decisions

  • Issue: PA decision past deadline
  • Solution: File complaint with Virginia Bureau of Insurance

Specialty Pharmacy Transfer Issues

  • Issue: Prescription stuck in transfer
  • Solution: Contact CVS Specialty directly at 866-814-5506

Frequently Asked Questions

Q: How long does Aetna PA take for Crysvita in Virginia? A: Standard review takes 30-45 days. Expedited review (with physician certification of urgency) takes 72 hours.

Q: What if Crysvita is non-formulary on my plan? A: Request a formulary exception with medical necessity documentation. Virginia external review can overturn non-formulary denials.

Q: Can I get expedited appeals in Virginia? A: Yes, both Aetna internal appeals and Virginia external review offer expedited timelines (72 hours) when delay could jeopardize health.

Q: Does step therapy apply to Crysvita? A: Some plans require documentation of inadequate response to oral phosphate and active vitamin D before approving Crysvita.

Q: What happens if I move from another state to Virginia? A: Prior therapy history from other states counts toward step therapy requirements. Gather all previous treatment records.

Q: How do I know if my appeal was successful? A: Aetna must provide written notice of all decisions. Approvals include authorization numbers and effective dates.

Q: Can I continue Crysvita during appeals? A: In urgent situations, request continuation of therapy during appeals. Virginia law supports this for ongoing treatments when stopping could cause harm.

Q: What if my employer's plan excludes Crysvita entirely? A: For self-funded plans, request an exception directly from the employer. Virginia external review may not apply to self-funded plans that haven't opted in.

At Counterforce Health, we help patients and clinicians turn insurance denials into successful appeals by creating targeted, evidence-backed rebuttal letters. Our platform analyzes denial reasons and drafts point-by-point responses aligned with each plan's specific policies, significantly improving approval rates for complex specialty medications like Crysvita.

For additional support navigating Aetna's prior authorization process, Counterforce Health can help you build a comprehensive appeal package that addresses Virginia-specific requirements and maximizes your chances of coverage approval.

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 decisions. Coverage policies and requirements may change. For personalized assistance with Virginia insurance appeals, contact the State Corporation Commission's Consumer Services at 1-877-310-6560.

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