By Counterforce Health Team in Crysvita (burosumab) —

How to Get Crysvita (burosumab) Covered by Cigna in Texas: Complete Forms, Appeals & Contact Guide

Answer Box: Getting Crysvita Covered by Cigna in Texas

Fastest path to approval: Submit Cigna's Crysvita Prior Authorization form with genetic/biochemical XLH confirmation and specialist documentation to fax 855-840-1678. Timeline: 72 hours standard, 24 hours expedited. If denied: File internal appeal within 180 days, then external review through Texas Department of Insurance within 4 months. Start today: Contact your endocrinologist to gather PHEX mutation results or FGF23 levels and request the PA form submission.

Table of Contents

  1. Verify Your Plan & Find Current Forms
  2. Prior Authorization Requirements
  3. Submission Portals & Methods
  4. Specialty Pharmacy Setup (Accredo)
  5. Appeals Process in Texas
  6. Support Contacts & Numbers
  7. Common Denial Reasons & Solutions
  8. Financial Assistance Options
  9. FAQ

Verify Your Plan & Find Current Forms

Before starting your Crysvita (burosumab) coverage request, confirm your specific Cigna plan type and coverage details:

Check Your Plan Status:

  • Log into myCigna to verify your specialty pharmacy benefits
  • Confirm if your plan uses Express Scripts/Accredo for specialty drugs
  • Note your member ID and group number for all submissions

Current Forms (2024):

Note: Forms are updated periodically. Always download the latest version from Cigna's official website before submission.

Prior Authorization Requirements

Cigna requires comprehensive documentation for Crysvita (burosumab) approval:

Coverage Criteria

Requirement Details Documentation Needed
Diagnosis X-linked hypophosphatemia (XLH) or tumor-induced osteomalacia (TIO) PHEX mutation testing OR elevated FGF23 + low serum phosphate
Age 6 months and older Patient birthdate
Prescriber Specialist required Endocrinologist, geneticist, nephrologist, or metabolic bone disease expert
Prior Therapy Adults: document oral phosphate/calcitriol failure or intolerance Chart notes, prescription history
Monitoring Plan Ongoing serum phosphate and kidney function Lab monitoring schedule

Required Clinical Documentation

Your specialist must provide:

  • Baseline serum phosphate and FGF23 levels
  • Genetic testing results (if available)
  • Treatment history and response to conventional therapy
  • Statement that competing therapies (oral phosphate/active vitamin D) will be discontinued
  • Weight-based dosing justification per FDA labeling

Submission Portals & Methods

Electronic Submission

  • Cigna Provider Portal: Precertification section (provider access required)
  • Express Scripts: Electronic prior authorization through provider portal

Fax Submission

  • Standard PA: 855-840-1678
  • Urgent requests: Call 800-882-4462 first, then fax supporting documents

Cover Sheet Tips

Include on all fax submissions:

  • Patient name and Cigna member ID
  • Prescriber name and NPI
  • "CRYSVITA PRIOR AUTHORIZATION - URGENT" (if applicable)
  • Number of pages being transmitted

Specialty Pharmacy Setup (Accredo)

Once approved, Cigna routes Crysvita through Accredo Specialty Pharmacy:

Patient Onboarding

  • Primary contact: 877-826-7657 (Mon-Sat, 7am-10pm CST)
  • General enrollment: 844-516-3319
  • Online account: accredo.com (requires Rx number)

Transfer from Another Pharmacy

  1. Call Accredo at 877-826-7657 with current pharmacy information
  2. Complete prescription transfer authorization
  3. Accredo coordinates with your current pharmacy and prescriber
  4. Expect 3-5 business days for transfer completion

Services Included

  • Clinical support and injection training
  • Side effect monitoring
  • Refill reminders and coordination
  • Insurance and copay assistance navigation

Appeals Process in Texas

If Cigna denies your Crysvita request, Texas law provides strong appeal rights:

Internal Appeal (First Step)

  • Timeline: 180 days from denial date to file
  • Cigna response: 30 days standard, 72 hours expedited
  • Submission: Cigna member portal or address on denial letter
  • Required: Original denial, member ID, medical records, specialist letter

External Review (Final Step)

  • Timeline: 4 months from final internal denial
  • Decision: 20 days standard, 72 hours expedited
  • Cost: Free to patient (Cigna pays IRO fees)
  • Binding: IRO decision is final and enforceable
Texas Advantage: Unlike some states, Texas provides robust external review rights for medical necessity denials, with expedited options for urgent cases.

Support Contacts & Numbers

Cigna Member Services

  • General: 1-800-88-CIGNA (1-800-882-4462)
  • Specialty pharmacy: Available through member portal
  • Peer-to-peer review: Request through provider services

Texas Regulatory Support

  • Texas Department of Insurance: 1-800-252-3439
  • IRO guidance: 1-866-554-4926
  • Office of Public Insurance Counsel: 1-877-611-6742

Accredo Specialty Pharmacy

  • Patient support: 877-826-7657
  • Prescriber fax: 888-302-1028
  • New enrollments: 844-516-3319

Common Denial Reasons & Solutions

Denial Reason Solution Strategy
Insufficient diagnostic evidence Submit PHEX mutation results or elevated FGF23 + low phosphate levels with reference ranges
Non-specialist prescriber Transfer prescription to endocrinologist, geneticist, or metabolic bone disease expert
Concurrent oral phosphate use Document discontinuation plan and clinical rationale for switching to Crysvita
Missing prior therapy documentation Provide prescription history and chart notes showing conventional therapy failure/intolerance
Quantity limit exceeded Submit weight-based dosing calculation with FDA labeling reference

Financial Assistance Options

Manufacturer Support

  • Kyowa Kirin Patient Support: Contact through prescriber or Accredo
  • Copay assistance: May be available for eligible commercial plans
  • Patient assistance program: For uninsured/underinsured patients

Foundation Resources

  • National Organization for Rare Disorders (NORD): Patient assistance programs
  • HealthWell Foundation: Specialty drug copay assistance
  • Patient Access Network Foundation: Rare disease coverage support

FAQ

How long does Cigna prior authorization take for Crysvita in Texas? Standard requests: 72 hours. Expedited requests: 24 hours. Submit complete documentation to avoid delays.

What if Crysvita is non-formulary on my Cigna plan? Request a formulary exception using Cigna's Texas exception form. Your specialist must document why formulary alternatives are inappropriate.

Can I request an expedited appeal in Texas? Yes, if delay would seriously jeopardize your health. Both Cigna and the Texas IRO must respond within 72 hours for expedited cases.

Does step therapy apply if I've failed conventional therapy outside Texas? Yes, document all prior treatments regardless of where they occurred. Include prescription records and clinical notes showing failure or intolerance.

What happens if Cigna denies my appeal? You can request binding external review through the Texas Department of Insurance within 4 months. The IRO's decision is final and enforceable.

How much does Crysvita cost without insurance? Cash prices typically range from $4,000-$40,000+ per vial depending on strength. Annual costs vary by weight and dosing schedule.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, identifies the specific denial basis, and drafts point-by-point rebuttals using the right clinical evidence and payer-specific requirements to maximize approval chances.

For complex Crysvita appeals or if you're facing repeated denials, consider partnering with coverage specialists who understand the nuances of rare disease approvals and can help strengthen your case with targeted evidence and proper procedural compliance.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance. For regulatory assistance in Texas, contact the Texas Department of Insurance at 1-800-252-3439.

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