By Counterforce Health Team in Crysvita (burosumab) —

How to Get Crysvita (Burosumab) Covered by Blue Cross Blue Shield in Washington: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Crysvita Covered in Washington

Yes, Blue Cross Blue Shield covers Crysvita (burosumab) in Washington with prior authorization. The fastest path: 1) Have your endocrinologist submit PA with genetic testing, biochemical labs (serum phosphate, FGF23), and step therapy documentation, 2) If denied, file internal appeal within 180 days, 3) Request external review through Washington's Insurance Commissioner if needed. Start by calling your specific Blue Cross plan (Premera: 800-722-1471, Regence: check member services) to confirm your formulary tier and requirements.

Table of Contents

Coverage Basics

Is Crysvita Covered by Blue Cross Blue Shield?

Blue Cross Blue Shield plans in Washington require prior authorization for Crysvita (burosumab) across all plan types. The medication is typically covered under the medical benefit rather than pharmacy formulary, using HCPCS code J0584.

Which Blue Cross Plans Operate in Washington?

Washington has two main Blue Cross Blue Shield plans:

  • Premera Blue Cross (largest commercial carrier)
  • Regence BlueShield (serves multiple states including Washington)

Both follow similar prior authorization frameworks but may have plan-specific variations in formulary placement and cost-sharing.

Note: Coverage policies vary between commercial, Medicare Advantage, and Medicaid (Apple Health) plans within the same carrier.

Prior Authorization Process

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all indications Blue Cross policies
Covered Indications XLH, TIO only FDA labeling
Prescriber Requirements Endocrinologist or metabolic bone specialist Plan policies
Authorization Period 12 months typical Standard across Blues
Step Therapy Required in most plans Plan-specific
Genetic Testing Required when available for XLH Clinical criteria

Step-by-Step: Fastest Path to Approval

  1. Gather Required Documentation (Patient/Clinic)
    • Genetic testing results (PHEX mutation for XLH)
    • Biochemical labs: serum phosphate, alkaline phosphatase, FGF23
    • Prior treatment history with oral phosphate and active vitamin D
    • ICD-10 codes (E83.31 for XLH)
  2. Specialist Consultation (Clinic)
    • Schedule with endocrinologist or metabolic bone disease specialist
    • Obtain detailed consultation notes supporting medical necessity
    • Timeline: 1-2 weeks for appointment
  3. Submit Prior Authorization (Prescriber)
    • Use Blue Cross provider portal or fax submission
    • Include complete medical necessity letter
    • Timeline: Same day submission possible
  4. Initial Review (Blue Cross)
    • Standard review: 5-15 business days
    • Expedited available for urgent cases
    • Timeline: Up to 30 days maximum
  5. Follow Up (Clinic/Patient)
    • Check authorization status via provider portal
    • Respond to any additional information requests
    • Timeline: Within 48 hours of requests
  6. Approval and Coordination (All parties)
    • Coordinate with specialty pharmacy for delivery
    • Schedule administration appointments
    • Timeline: 3-5 days for medication delivery
  7. Treatment Initiation (Healthcare team)
    • Begin monitoring protocol per FDA guidelines
    • Document response for future renewals
    • Timeline: Ongoing per dosing schedule

Step Therapy Requirements

Required First-Line Treatments

Blue Cross Blue Shield typically requires documentation of failure or contraindication to:

  • Oral phosphate supplements (sodium phosphate or potassium phosphate)
  • Active vitamin D analogs (calcitriol, doxercalciferol, or paricalcitol)

Step Therapy Bypass Criteria

Step therapy may be bypassed with documentation of:

  • Medical contraindications to conventional therapy
  • Previous intolerance with documented adverse effects
  • Clinical evidence that conventional therapy is inappropriate
Critical Warning: Crysvita is contraindicated with concurrent use of oral phosphate and active vitamin D. These must be discontinued before starting burosumab.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Lack of genetic confirmation Submit PHEX mutation testing Genetic lab report
Missing biochemical evidence Provide complete lab panel Serum phosphate, FGF23, alkaline phosphatase
Inadequate step therapy Document prior failures/contraindications Treatment history, adverse event notes
Wrong prescriber Get specialist consultation Endocrinologist evaluation
Missing monitoring plan Submit detailed protocol Serum phosphorus monitoring schedule
Quantity limit exceeded Justify weight-based dosing Patient weight, dosing calculation

Clinician Corner: Medical Necessity Letter Checklist

When drafting your medical necessity letter, include:

✓ Patient diagnosis with ICD-10 codes (E83.31 for XLH)
✓ Biochemical evidence - specific lab values and dates
✓ Prior treatment history - medications tried, duration, outcomes
✓ Contraindications or intolerances to conventional therapy
✓ Clinical rationale citing FDA prescribing information
✓ Proposed dosing schedule based on patient weight
✓ Monitoring plan for serum phosphorus and safety
✓ Expected clinical outcomes and treatment goals

Reference the FDA prescribing information and relevant clinical guidelines in your justification.

Appeals Process in Washington

Internal Appeals (First Level)

Timeline: 180 days from denial date
Process: Submit through Blue Cross member/provider portal
Required: Original PA request, denial letter, additional supporting documentation

External Review (Independent Review Organization)

Washington provides strong consumer protections through external review per RCW 48.43.535.

When to File: After final internal denial
Timeline: 180 days from final internal denial
Process: Submit request to Washington Insurance Commissioner's office
Contact: 1-800-562-6900 (Consumer Advocacy line)

Appeals Playbook for Blue Cross Blue Shield in Washington

  1. Internal Appeal (Level 1)
    • Submit within 180 days of denial
    • Include new clinical evidence if available
    • Request peer-to-peer review if offered
    • Timeline: 30 days for decision
  2. Internal Appeal (Level 2) (if applicable)
    • Some plans offer second internal review
    • Submit within specified timeframe
    • Timeline: 30 days for decision
  3. External Review (IRO)
    • File with Washington Insurance Commissioner
    • Independent medical experts review case
    • Decision is binding on insurer
    • Timeline: 30 days standard, 72 hours expedited
From our advocates: We've seen several Washington patients successfully overturn Crysvita denials through external review when the initial denial was based on incomplete understanding of rare disease criteria. The key was providing comprehensive genetic and biochemical documentation that clearly met FDA-approved indications. While outcomes vary, thorough preparation significantly improves success rates.

Costs & Financial Assistance

Understanding Your Costs

Crysvita is typically covered under medical benefit with:

  • Deductible applies: Yes, for most plans
  • Coinsurance: Usually 10-30% after deductible
  • Annual out-of-pocket maximum: Protects against unlimited costs

Financial Assistance Options

  • Kyowa Kirin Cares Program: Patient assistance and copay support
  • Foundation grants: Limited income-based assistance available
  • State programs: Washington Apple Health (Medicaid) for eligible patients

Contact the Kyowa Kirin Cares program to explore assistance options.

Renewal Requirements

When to Reauthorize

Most Blue Cross plans require reauthorization every 12 months. Begin the renewal process 30-60 days before expiration.

Documentation for Renewal

  • Clinical response evidence: Improved serum phosphorus levels
  • Radiographic improvements: If applicable
  • Adherence documentation: At least 85% compliance
  • Continued medical necessity: Updated specialist evaluation

Monitoring Requirements

Ongoing monitoring includes:

  • Serum phosphorus levels every 2 weeks initially, then monthly
  • Serum or urine calcium monitoring
  • Vitamin D metabolite levels
  • Nephrocalcinosis screening via ultrasound or CT

Specialty Pharmacy Coordination

Why Specialty Pharmacy?

Crysvita requires:

  • Cold chain storage and handling
  • Patient education on injection technique
  • Coordination with healthcare providers
  • Insurance benefits verification

Administration Options

  • Healthcare provider office: Most common
  • Home administration: With trained nursing support
  • Infusion center: For complex cases

Counterforce Health helps streamline the specialty pharmacy coordination process by ensuring all documentation meets payer requirements upfront, reducing delays in medication access.

When to Escalate

Contact Washington Insurance Commissioner

If you experience:

  • Unreasonable delays in review
  • Procedural violations
  • Denial despite meeting criteria

Contact Information:
Washington State Office of the Insurance Commissioner
Phone: 1-800-562-6900
Website: insurance.wa.gov

Filing a Complaint

The Insurance Commissioner can investigate:

  • Claims handling violations
  • Unreasonable denials
  • Failure to follow state law

Frequently Asked Questions

How long does Blue Cross Blue Shield prior authorization take in Washington?
Standard review takes 5-15 business days, with a maximum of 30 days. Expedited review is available for urgent medical situations.

What if Crysvita is non-formulary on my plan?
You can request a formulary exception with medical necessity documentation. External review is available if the exception is denied.

Can I request an expedited appeal in Washington?
Yes, expedited appeals are available when delays could seriously jeopardize your health. External review can be expedited to 72 hours.

Does step therapy apply if I failed treatments outside Washington?
Yes, documented treatment failures from other states are typically accepted with proper medical records.

What happens if I miss a reauthorization deadline?
Contact your prescriber immediately to submit a new prior authorization. Some plans may allow retroactive coverage with justification.

Can I appeal to multiple levels simultaneously?
No, you must complete each level before proceeding to the next. However, you can request expedited review at each level.

What if my employer plan is self-funded?
Self-funded ERISA plans may not follow Washington state appeal laws. Contact the U.S. Department of Labor for ERISA plan appeals guidance.

How do I find my specific Blue Cross plan's formulary?
Check your member portal, call member services, or visit your plan's website. Premera and Regence maintain searchable drug lists online.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For additional support navigating insurance appeals and prior authorization requirements, Counterforce Health provides specialized assistance in turning insurance denials into successful, evidence-backed appeals.

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