By Counterforce Health Team in Crysvita (burosumab) —

How to Get Crysvita (burosumab) Covered by Anthem Blue Cross Blue Shield Virginia: Prior Authorization, Appeals & External Review Guide

Answer Box: Getting Crysvita Covered by Anthem BCBS Virginia

Anthem Blue Cross Blue Shield Virginia requires prior authorization for Crysvita (burosumab) with strict clinical criteria. To get approval: (1) Your endocrinologist submits genetic XLH confirmation plus low serum phosphorus labs via Anthem's clinical criteria portal, (2) Document failed/contraindicated oral phosphate + vitamin D therapy, (3) Use in-network specialty pharmacy like CVS Specialty or BioPlus. If denied, appeal within 180 days, then request Virginia external review through the State Corporation Commission (free, 120-day window). Start today: Call the number on your insurance card to verify PA requirements and download Form 216-A for potential appeals.

Table of Contents

  1. Anthem BCBS Virginia Plan Types & Network Rules
  2. Crysvita Formulary Status & Tier Placement
  3. Prior Authorization Requirements & Clinical Criteria
  4. Specialty Pharmacy Network & Dispensing
  5. Cost-Sharing & Coverage Dynamics
  6. PA Submission Process & Required Forms
  7. Common Approval Patterns & Success Factors
  8. Appeals Process: Internal & Virginia External Review
  9. Cost Assistance & Patient Support Programs
  10. FAQ: Virginia-Specific Questions

Plan Types & Network Implications

Anthem Blue Cross Blue Shield dominates Virginia's commercial insurance market with approximately 43% market share. In Virginia, Anthem operates through Anthem Health Plans of Virginia, Inc. and HealthKeepers, Inc., serving different geographic regions with some variations in network and policies.

Key plan distinctions for Crysvita coverage:

  • Commercial plans (employer-sponsored): Follow Anthem's standard clinical criteria with 180-day internal appeal rights
  • ACA marketplace plans: Same clinical criteria but may have different specialty pharmacy networks
  • Medicare Advantage: More restrictive criteria and shorter appeal windows (60 days)
  • Self-funded employer plans: May adopt, modify, or exclude Anthem's standard Crysvita criteria entirely
Note: Self-funded plans (check your benefits summary or call member services) may have completely different rules despite using Anthem's network.

Crysvita Formulary Status & Tier Placement

Crysvita appears on Anthem Virginia's specialty pharmacy precertification list under HCPCS code J0584, indicating it requires prior authorization regardless of formulary tier. The medication is covered under the medical benefit (not pharmacy benefit) for most Virginia plans.

Coverage specifics:

  • Prior authorization required for all Virginia Anthem plans
  • Specialty pharmacy dispensing mandatory through designated network
  • Medical benefit coverage (billed through medical claims, not prescription)
  • No specific formulary tier listed (medical benefit drugs aren't tiered like pharmacy benefit medications)

You can verify your specific plan's coverage at Anthem's Virginia drug formulary page or by calling 1-800-331-1476.

Prior Authorization Requirements & Clinical Criteria

Anthem Virginia's clinical criteria for Crysvita align with FDA labeling but include additional documentation requirements. Based on Anthem's published clinical criteria updates, approval requires meeting all of the following:

Eligible Diagnoses

  • X-linked hypophosphatemia (XLH) in patients ≥6 months old
  • Tumor-induced osteomalacia (TIO) in patients ≥2 years when tumor is unresectable or cannot be localized

Required Clinical Documentation

Requirement What You Need ICD-10 Code
Low serum phosphorus Fasting level below age-adjusted normal range E83.31 (Familial hypophosphatemia)
Genetic confirmation PHEX mutation test or first-degree relative with confirmed XLH Z87.891 (Personal history of nicotine dependence)
Radiographic evidence X-rays showing rickets, osteomalacia, or fractures M83.9 (Adult osteomalacia, unspecified)
Specialist prescriber Endocrinologist, nephrologist, or metabolic bone specialist -
Prior therapy documentation Trial/contraindication to oral phosphate + active vitamin D -

Critical Lab Requirements

  • Fasting serum phosphorus (must be below normal)
  • Alkaline phosphatase (often elevated)
  • 25-OH vitamin D (should be adequate before starting)
  • Parathyroid hormone (PTH)
  • Serum calcium
Clinician Corner: Discontinue oral phosphate supplements and active vitamin D (calcitriol) one week before starting Crysvita per FDA labeling. Document this timing in your PA submission.

Specialty Pharmacy Network & Dispensing

Anthem Virginia requires Crysvita to be dispensed through designated specialty pharmacies. For Virginia members, in-network options include:

Medical Benefit Specialty Pharmacies:

  • CVS Specialty (primary option for most plans)
  • BioPlus Specialty Pharmacy
  • CenterWell Pharmacy
  • Paragon Healthcare (added January 1, 2025)

Additional Pharmacy Benefit Options:

  • CareMed Specialty Pharmacy
  • Harness Health Pharmacy
  • Inova Retail and Specialty Pharmacy
  • MedStar Specialty Pharmacy
  • MUSC Health Specialty Pharmacy Services

Patient enrollment process:

  1. Your doctor's office initiates the specialty pharmacy referral
  2. Specialty pharmacy contacts you within 24-48 hours
  3. Complete intake call (insurance verification, delivery preferences)
  4. Schedule first injection (office visit or home health)
Tip: Verify your specific plan's preferred specialty pharmacy by calling member services, as out-of-network specialty pharmacies may result in higher costs or denials.

Cost-Sharing & Coverage Dynamics

Crysvita's high cost (WAC prices: $4,451-$13,354 per vial depending on strength) means cost-sharing can be substantial even with insurance coverage.

Typical Virginia Anthem cost-sharing patterns:

  • Deductible applies first (often $1,000-$5,000 for individual coverage)
  • Coinsurance: 20-30% after deductible for specialty drugs
  • Out-of-pocket maximum: $8,550-$9,450 for individual coverage (2024 ACA limits)

Monthly cost examples (educational only):

  • 30 mg dose (common pediatric): ~$13,354 × 20% = $2,671 coinsurance per month
  • 90 mg dose (adult): ~$40,062 × 20% = $8,012 coinsurance per month
Important: These are illustrative examples only. Your actual costs depend on your specific plan design, deductible status, and any applicable cost-sharing reductions.

PA Submission Process & Required Forms

Step-by-Step Submission Process

  1. Verify benefits (Provider): Call Anthem provider services or use online portal to confirm PA requirement and specialty pharmacy network
  2. Download PA form (Provider): Access current burosumab clinical criteria form from Anthem's Clinical Criteria page
  3. Gather documentation (Provider + Patient):
    • Genetic test results (PHEX mutation)
    • Recent labs (within 30-60 days)
    • Imaging reports showing bone disease
    • Prior therapy records (phosphate + vitamin D trials)
    • Growth charts (pediatric patients)
  4. Submit complete PA (Provider): Via Anthem provider portal or fax to designated PA department
  5. Await determination (Patient + Provider): Standard review takes 7-14 business days; expedited review available for urgent cases
  6. If approved (Patient): Specialty pharmacy will contact you to coordinate delivery and injection scheduling
  7. If denied (Patient + Provider): Review denial letter and initiate internal appeal within 180 days

Required PA Form Elements

  • Patient demographics and insurance information
  • Diagnosis with ICD-10 code (E83.31 for XLH)
  • Prescriber information and specialty credentials
  • Requested dose and frequency (must align with FDA labeling)
  • Clinical justification narrative addressing all criteria points
  • Supporting documentation attachments

Common Approval Patterns & Success Factors

Based on Anthem's clinical criteria and common payer patterns, successful Crysvita PAs typically include:

Strong Submissions Include:

  • Complete genetic documentation: PHEX mutation report or confirmed family history
  • Objective disease severity: Radiographic evidence of active bone disease, fractures, or deformities
  • Biochemical confirmation: Fasting hypophosphatemia with elevated/inappropriate alkaline phosphatase
  • Prior therapy narrative: Clear documentation of phosphate/vitamin D trial, response, and discontinuation reasons
  • Specialist endorsement: Letter from metabolic bone specialist or pediatric endocrinologist

Common Denial Reasons:

  • Missing genetic confirmation of XLH
  • Inadequate documentation of bone disease severity
  • Lack of prior conventional therapy trial
  • Incomplete lab work or outdated values
  • Non-specialist prescriber without consultation documentation
From our advocates: "We've seen Virginia patients succeed by having their endocrinologist write a detailed letter explaining why oral phosphate caused kidney stones, making Crysvita medically necessary. The key was documenting the specific adverse effects, not just saying 'failed prior therapy.'"

Appeals Process: Internal & Virginia External Review

Internal Appeals (Anthem)

Timeline: 180 days from denial notice to file Process:

  1. Submit written appeal with additional clinical documentation
  2. Request peer-to-peer review between your specialist and Anthem medical director
  3. Include any new labs, imaging, or specialist consultations
  4. Anthem has 30 days for standard review, 72 hours for expedited

Key appeal strategies:

  • Address each specific denial reason with new evidence
  • Cite Anthem's own clinical criteria and show how you meet requirements
  • Include updated clinical notes showing disease progression or complications

Virginia External Review Process

If Anthem upholds the denial, Virginia law provides free external review through the State Corporation Commission Bureau of Insurance.

Eligibility requirements:

  • Completed Anthem's internal appeals process
  • Denial based on medical necessity, experimental treatment, or similar clinical judgment
  • Virginia-issued plan or opted-in self-funded plan

Required forms:

  • Form 216-A (External Review Request)
  • Form 216-B (if filing through authorized representative)
  • Form 216-C (Physician Certification for expedited review)

Submission methods:

  • Email: [email protected]
  • Fax: (804) 371-9915
  • Mail: State Corporation Commission, Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218
  • Phone support: 1-877-310-6560

Timeline:

  • Standard review: 45 days for decision
  • Expedited review: 72 hours (requires physician certification of urgency)
  • Filing deadline: 120 days from Anthem's final denial notice

Important: Virginia's external review is binding on Anthem. If overturned, they must authorize coverage within 24-72 hours.

Cost Assistance & Patient Support Programs

Manufacturer Support Programs

  • Kyowa Kirin Patient Support: Provides copay assistance and free genetic testing through Invitae
  • Financial assistance programs: Income-based support for eligible patients
  • Clinical support services: Injection training and adherence monitoring

Virginia-Specific Resources

  • Virginia Medicaid: Covers Crysvita with prior authorization for eligible patients
  • Virginia Poverty Law Center: Free legal assistance for insurance appeals
  • State Corporation Commission Consumer Services: Free guidance on appeal rights (1-877-310-6560)

Foundation Support

  • Patient Advocate Foundation: Copay relief program for qualifying rare disease patients
  • HealthWell Foundation: Financial assistance for hypophosphatemia treatments
  • National Organization for Rare Disorders (NORD): Patient assistance programs

FAQ: Virginia-Specific Questions

Q: How long does Anthem BCBS Virginia PA review take? A: Standard review takes 7-14 business days. Expedited review (for urgent medical situations) takes 72 hours. You can request expedited review if delay would seriously jeopardize health.

Q: What if Crysvita is denied as "experimental"? A: This suggests inadequate documentation of FDA-approved indication (XLH or TIO). Appeal with genetic confirmation, specialist consultation, and clear diagnosis documentation.

Q: Can I use any specialty pharmacy in Virginia? A: No. Anthem requires use of designated in-network specialty pharmacies. Using out-of-network pharmacies may result in denial or significantly higher costs.

Q: Does Virginia external review cost money? A: No. Virginia provides free external review for all eligible cases. There are no filing fees or administrative costs.

Q: What if my employer plan is self-funded? A: Self-funded plans may have different criteria than standard Anthem policies. Check your Summary Plan Description or contact HR. Some self-funded plans opt into Virginia's external review process.

Q: How often does Crysvita need reauthorization? A: Typically annually. Renewal requires documentation of clinical benefit (improved phosphorus levels, reduced fractures, better growth in children).

Q: Can I appeal if I'm denied for "step therapy"? A: Yes. Document medical reasons why oral phosphate and active vitamin D are inappropriate (kidney stones, nephrocalcinosis, severe GI intolerance) and appeal based on contraindication.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for patients seeking coverage of specialty medications like Crysvita. Our platform analyzes denial letters, identifies the specific coverage gaps, and helps create evidence-backed appeals that address payer-specific criteria. For complex cases involving rare disease treatments, we work with patients, clinicians, and specialty pharmacies to navigate the prior authorization process and improve approval rates.

For Virginia patients facing Crysvita denials, Counterforce Health can help develop targeted appeal strategies that leverage both Anthem's clinical criteria and Virginia's external review process to maximize your chances of coverage approval.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms, medical circumstances, and current policies. Always consult with your healthcare provider and insurance company for guidance specific to your situation. Virginia residents should contact the State Corporation Commission Bureau of Insurance at 1-877-310-6560 for official guidance on appeal rights and procedures.

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