By Counterforce Health Team in Crysvita (burosumab) —

How to Get Crysvita (burosumab) Covered by Cigna in Ohio: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Crysvita Covered by Cigna in Ohio

Crysvita (burosumab) requires prior authorization from Cigna in Ohio, typically placed on Tier 4-5 specialty with 20-33% coinsurance. You'll need genetic confirmation (PHEX mutation or elevated FGF23), low baseline serum phosphorus, and specialist prescriber. Submit PA through Cigna's provider portal or CoverMyMeds. If denied, file internal appeal within 180 days, then external review through Ohio Department of Insurance (1-800-686-1526). Most specialty drug appeals succeed with complete documentation. First step: Have your endocrinologist gather genetic tests, recent labs, and clinical notes before submitting the PA form.

Table of Contents

  1. Cigna Plan Types & Coverage in Ohio
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Process
  5. Cost-Sharing & Financial Assistance
  6. Submission Process & Forms
  7. Appeals Process for Ohio
  8. Common Denial Reasons & Solutions
  9. Frequently Asked Questions

Cigna Plan Types & Coverage in Ohio

Ohio residents access Crysvita through different Cigna products, each with specific coverage rules:

Commercial Plans (Employer-Based)

Medicare Advantage Plans

Individual/ACA Marketplace Plans

  • Available through Healthcare.gov in Ohio
  • Must comply with essential health benefits
  • External review rights through Ohio Department of Insurance
Note: Self-funded employer plans follow federal ERISA law but often use Ohio's external review process voluntarily.

Formulary Status & Tier Placement

Crysvita appears on Cigna's specialty drug list as a high-cost biologic requiring prior authorization.

Coverage at a Glance

Requirement Details How to Verify
Prior Authorization Required for all indications Cigna PA Policy
Formulary Tier Tier 4-5 Specialty Check plan's drug list via Cigna portal
Step Therapy May require oral phosphate + calcitriol trial Plan-specific; review PA criteria
Quantity Limits Weight-based dosing per FDA label FDA-approved dosing tables
Age Restrictions ≥6 months (XLH), ≥2 years (TIO) FDA labeling
Specialist Required Endocrinologist, nephrologist, or metabolic bone specialist PA form requirement

Formulary Alternatives For X-linked hypophosphatemia (XLH), traditional therapy includes oral phosphate supplements plus active vitamin D (calcitriol). However, Crysvita represents a significant advancement for patients who don't respond adequately to conventional treatment.

Prior Authorization Requirements

Cigna's national coverage policy requires ALL of the following for initial approval:

For X-Linked Hypophosphatemia (XLH)

1. Confirmed Diagnosis

  • PHEX gene mutation on genetic testing, OR
  • Elevated FGF23 level above upper limit of normal

2. Biochemical Evidence

  • Fasting serum phosphorus below age-adjusted normal range
  • Recent labs (within 30-90 days)

3. Clinical Documentation

  • Evidence of rickets, bone pain, fractures, or growth retardation
  • Functional impact on daily activities

4. Prescriber Requirements

  • Must be prescribed by or in consultation with:
    • Endocrinologist
    • Nephrologist
    • Metabolic bone specialist

5. Prior Therapy Documentation

  • Trial of oral phosphate + active vitamin D (calcitriol), with:
    • Inadequate response
    • Intolerance
    • Medical contraindication

For Tumor-Induced Osteomalacia (TIO)

1. Confirmed FGF23-Related Hypophosphatemia

  • Documented phosphaturic mesenchymal tumor
  • Tumor cannot be resected or localized

2. Supporting Evidence

  • Imaging reports showing unresectable/unlocalized tumor
  • Surgical consultation notes (if applicable)
Tip: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for complex medications like Crysvita, helping patients navigate the prior authorization process more effectively.

Specialty Pharmacy Process

Cigna routes Crysvita through Accredo, their specialty pharmacy partner under Express Scripts.

Step-by-Step Process

1. Prescription Submission (Provider)

  • Submit electronically via NCPDP, Surescripts, or MyAccredoPatients portal
  • Include 90-day supply with refills for efficiency
  • Timeline: Same day processing

2. Prior Authorization (Automated)

  • Accredo coordinates with Cigna for PA approval
  • Submit via CoverMyMeds or Cigna provider portal
  • Timeline: 5-7 business days

3. Patient Enrollment

  • Accredo patient care advocate contacts patient within 2-3 days
  • Provides injection training and administration support
  • Sets up delivery schedule (every 2-4 weeks)

4. Ongoing Support

  • 24/7 pharmacist access
  • Therapeutic Resource Center services
  • Automatic refill reminders

Patient Portal Access

  • Track shipments via Accredo app or myCigna
  • Schedule deliveries around travel
  • Access clinical support services

Cost-Sharing & Financial Assistance

Typical Cost Structure

Tier 4-5 Specialty Coinsurance: 20-33% of drug cost

  • Single-dose vial pricing (2024):
    • 10 mg/mL: $4,451.45
    • 20 mg/mL: $8,902.91
    • 30 mg/mL: $13,354.36

Medicare Advantage (2025)

  • $2,000 annual Part D out-of-pocket maximum
  • Once reached, $0 copay for rest of year

Commercial Plans

  • Subject to plan's annual out-of-pocket maximum
  • Typically $3,000-$8,000 for individual coverage

Financial Assistance Options

Manufacturer Support

Foundation Grants

  • Patient Advocate Foundation
  • National Organization for Rare Disorders (NORD)

State Resources

  • Ohio pharmaceutical assistance programs
  • Medicaid expansion coverage for eligible adults

Submission Process & Forms

Required Documentation Checklist

Clinical Records

  • Specialist consultation notes
  • Genetic test results (PHEX mutation or FGF23 levels)
  • Recent lab reports with reference ranges
  • Prior therapy documentation
  • Growth charts (pediatric patients)

Administrative Forms

  • Cigna Crysvita PA form
  • ICD-10 diagnosis codes (E83.30 for phosphorus disorders)
  • Prescriber NPI and specialty verification

Submission Methods

Electronic (Fastest)

  • Cigna provider portal
  • CoverMyMeds platform
  • Surescripts network

Traditional

  • Fax: 855-840-1678 (verify current number)
  • Mail to address on PA form

Timeline Expectations

  • Standard review: 5-10 business days
  • Expedited review: 72 hours (urgent medical need)

Appeals Process for Ohio

Ohio law provides robust appeal rights for Cigna members, with multiple levels of review.

Internal Appeals

Level 1 Appeal

  • Deadline: 180 days from denial notice
  • Timeline: 30 days for decision (72 hours if expedited)
  • Submit: New clinical evidence, specialist letters, updated labs

Level 2 Appeal

  • Deadline: 60 days from Level 1 denial
  • Timeline: 30 days for decision
  • Review: Different clinical reviewer

External Review (Ohio Department of Insurance)

Eligibility

  • Available after exhausting internal appeals
  • Covers medical necessity determinations
  • Free to patients

Process

  • Deadline: 60-180 days from final internal denial
  • Contact: Ohio Department of Insurance at 1-800-686-1526
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Outcome: Binding on Cigna if overturned
Note: Counterforce Health helps patients and clinicians craft compelling appeals by analyzing denial letters and aligning responses with payer-specific criteria and clinical evidence.

Success Factors

Research shows specialty drug appeals succeed over 66% of the time when supported by:

  • Complete clinical documentation
  • Specialist attestation of medical necessity
  • Evidence of prior therapy failures
  • Clear functional impact documentation

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Insufficient genetic evidence Submit PHEX mutation report or elevated FGF23 Genetic test results with interpretation
Missing baseline labs Provide fasting serum phosphorus below normal Lab report with reference ranges
Lack of specialist involvement Obtain endocrinology consultation Specialist evaluation note
Inadequate prior therapy trial Document oral phosphate + calcitriol use Treatment records showing inadequacy/intolerance
Age criteria not met Verify FDA-approved age ranges Birth certificate or medical record confirmation
Medical necessity unclear Strengthen clinical narrative Functional assessment, quality of life impact

Medical Necessity Letter Template

When appealing, include a letter addressing:

  1. Clinical problem: XLH/TIO diagnosis and complications
  2. Prior treatments: Oral phosphate/calcitriol trial outcomes
  3. Medical rationale: Why Crysvita is necessary
  4. Evidence base: FDA approval, clinical guidelines
  5. Monitoring plan: Follow-up labs and assessments

Frequently Asked Questions

How long does Cigna prior authorization take in Ohio? Standard PA decisions take 5-10 business days. Expedited reviews (for urgent medical need) are completed within 72 hours per Ohio law.

What if Crysvita is non-formulary on my plan? Request a formulary exception through Cigna's standard process. Provide medical necessity documentation showing no equally effective alternatives exist.

Can I request an expedited appeal in Ohio? Yes, if delay would seriously jeopardize your health. Your physician must certify the urgent nature, and decisions come within 72 hours.

Does step therapy apply if I've tried oral phosphate outside Ohio? Yes, treatment history from other states counts. Provide documentation of prior therapy trials and outcomes regardless of location.

What's the difference between medical and pharmacy benefit coverage? Crysvita may be covered under pharmacy benefit (Accredo specialty pharmacy) or medical benefit (office/infusion center administration). Check with Cigna to confirm which applies to your plan.

How do I track my appeal status? Use the Cigna member portal or call the number on your ID card. Keep your appeal reference number for tracking.

What if my employer plan is self-funded? Self-funded ERISA plans may use different appeal processes, but many voluntarily follow Ohio's external review procedures. Check your Summary Plan Description for specific rights.

Are there income limits for manufacturer assistance? Ultragenyx patient support programs have income-based eligibility. Contact them directly to determine qualification.

This guide provides educational information about insurance coverage and is not medical advice. Always consult your healthcare provider about treatment decisions. For official information about Ohio insurance regulations, contact the Ohio Department of Insurance at 1-800-686-1526.

Sources & Further Reading

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