By Counterforce Health Team in Crysvita (burosumab) —

How to Get Crysvita (burosumab) Covered by Humana in Pennsylvania: Prior Authorization, Appeals, and Alternative Options

Answer Box: Getting Crysvita (burosumab) Covered by Humana in Pennsylvania

Crysvita (burosumab) requires prior authorization from Humana in Pennsylvania. For Medicare Advantage members, submit PA documentation including genetic/FGF23 confirmation of XLH, baseline low serum phosphorus, and specialist attestation via Humana's provider portal. Standard review takes 72 hours; expedited decisions within 24-48 hours for urgent cases. If denied, file internal appeals within 65 days, then pursue federal Medicare appeals (not Pennsylvania's state external review, which excludes Medicare plans). Commercial Humana members can use Pennsylvania's Independent External Review after internal appeals, with 50% overturn rates in 2024.

First step today: Contact your prescriber to initiate prior authorization through Humana's provider portal with required XLH documentation.

Table of Contents

  1. When Formulary Alternatives Make Sense
  2. Typical Alternatives to Crysvita
  3. Pros and Cons Overview
  4. Exception Strategy for Non-Formulary Coverage
  5. Switching Logistics and Coordination
  6. Re-trying for Crysvita Later
  7. Appeals Playbook for Humana in Pennsylvania
  8. FAQ

When Formulary Alternatives Make Sense

If Crysvita (burosumab) faces formulary restrictions with your Humana plan in Pennsylvania, understanding when alternatives are appropriate can help you and your clinician develop an effective strategy.

Crysvita is not listed as a preferred drug in Humana's 2026 Medicare Advantage Part B formulary, indicating it requires prior authorization or formulary exception for coverage. Before pursuing expensive appeal processes, your healthcare team may recommend trying conventional XLH treatments first—particularly if you're newly diagnosed or haven't exhausted traditional options.

Clinical Scenarios Where Alternatives Are Considered

Initial diagnosis scenarios:

  • Newly confirmed XLH via PHEX gene mutation or elevated FGF23 (>30 pg/mL)
  • Mild symptoms without significant bone deformities or fractures
  • Pediatric patients where conventional therapy compliance is achievable
  • Adults with stable disease seeking to establish treatment response

Insurance-driven scenarios:

  • Step therapy requirements mandating conventional treatment trial
  • High out-of-pocket costs for Crysvita while alternatives have lower copays
  • Formulary restrictions requiring 3-6 month documented failure of standard therapy
Note: Per FDA labeling and payer policies, conventional phosphate plus active vitamin D should not be used concurrently with Crysvita due to hypercalciuria and nephrocalcinosis risks.

Typical Alternatives to Crysvita

Conventional XLH Treatment (First-Line)

Phosphate supplements combined with active vitamin D analogs remain the standard approach for many patients:

Phosphate formulations:

  • Potassium phosphate (K-Phos Neutral, Neutra-Phos)
  • Sodium phosphate preparations
  • Typical dosing: 1-3 grams phosphorus daily, divided 4-5 times

Active vitamin D analogs:

  • Calcitriol (Rocaltrol): 0.25-2 mcg daily, divided 1-2 times
  • Alfacalcidol (not FDA-approved in US; available via special programs)
  • Paricalcitol (Zemplar): alternative for patients with hyperparathyroidism

Supportive Care Options

Orthopedic interventions:

  • Corrective osteotomies for severe bowing deformities
  • Fracture management and pseudofracture monitoring
  • Physical therapy for mobility and strength

Dental care:

  • Regular monitoring for dental abscesses
  • Prophylactic antibiotics for dental procedures
  • Specialized endodontic care for XLH-related complications

Pros and Cons Overview

Aspect Conventional Therapy Crysvita (burosumab)
Access Generally formulary-covered; lower copays Requires PA; high cost ($4,000-$40,000+ annually)
Dosing Multiple daily doses (phosphate 4-5x, calcitriol 1-2x) Subcutaneous injection every 2-4 weeks
Monitoring Frequent labs (phosphorus, calcium, PTH, kidney function) Less frequent monitoring; FGF23 tracking
Efficacy Modest phosphate correction; persistent symptoms common Superior bone healing (69% vs 8% radiographic improvement)
Side Effects GI upset, hyperparathyroidism, nephrocalcinosis risk Hypersensitivity reactions, injection site reactions
Long-term Chronic kidney disease risk; supply shortages Limited long-term safety data (approved 2018)

Access Considerations for Pennsylvania Residents

Conventional therapy advantages:

  • Most Humana plans cover phosphate supplements under standard pharmacy benefits
  • Calcitriol typically requires minimal prior authorization
  • Generic options reduce out-of-pocket costs

Crysvita access challenges:

  • Not on Humana's preferred Part B formulary for 2026
  • Requires specialty pharmacy coordination through CenterWell
  • May require medical exception or appeals process

Exception Strategy for Non-Formulary Coverage

When Crysvita isn't covered, Humana's formulary exception process can provide access based on medical necessity.

Medical Necessity Documentation Requirements

Your prescriber must submit a supporting statement demonstrating that:

  1. All covered formulary alternatives would be less effective for your specific XLH presentation
  2. Covered alternatives would cause adverse effects based on your medical history
  3. Clinical evidence supports Crysvita's necessity for your case

Key Evidence to Include

Diagnostic confirmation:

  • PHEX gene mutation testing results
  • Elevated FGF23 levels (reference range typically <30 pg/mL)
  • Baseline fasting serum phosphorus below normal range
  • Low tubular maximum reabsorption of phosphate per GFR (TmP/GFR)

Treatment failure documentation:

  • Detailed trial history of phosphate supplements and calcitriol
  • Documented adverse effects (GI intolerance, hyperparathyroidism, nephrocalcinosis)
  • Persistent symptoms despite adequate conventional therapy trial (≥3-6 months)
  • Radiographic evidence of ongoing rickets or osteomalacia

Clinical impact evidence:

  • Bone pain limiting daily activities
  • Recurrent fractures or pseudofractures
  • Growth delay in pediatric patients
  • Functional impairment affecting quality of life
Clinician Corner: When drafting medical necessity letters, reference FDA labeling indications and cite peer-reviewed studies demonstrating Crysvita's superior efficacy in XLH management. Include specific lab values and imaging findings to strengthen the clinical rationale.

Switching Logistics and Coordination

Humana-Specific Process

Step 1: Provider Portal Submission Submit prior authorization through Humana's provider portal including:

  • Patient demographics and Humana member ID
  • HCPCS code J3490 or J3590 with NDC
  • Diagnosis codes (E83.39 for XLH)
  • Complete medical necessity documentation

Step 2: Specialty Pharmacy Coordination Humana requires specialty medications like Crysvita to be dispensed through CenterWell Specialty Pharmacy:

  • Provider submits prescription to CenterWell
  • Pharmacy coordinates with Humana for coverage verification
  • Patient receives injection training and supplies

Step 3: Monitoring Plan Establish monitoring protocol per FDA labeling:

  • Baseline and periodic serum phosphorus
  • Calcium and parathyroid hormone levels
  • Kidney function assessment
  • Discontinue phosphate supplements and calcitriol before starting Crysvita

Timeline Expectations

Review Type Timeline Notes
Standard PA 72 hours Most common for stable patients
Expedited PA 24-48 hours Requires physician certification of urgency
Electronic submission 1 business day Humana's 95% target for 2026

Re-trying for Crysvita Later

If initial attempts for Crysvita coverage fail, documenting your experience with alternatives strengthens future requests.

Documentation During Alternative Therapy

Track treatment response:

  • Serial serum phosphorus levels
  • Pain scores and functional assessments
  • Growth measurements in pediatric patients
  • Radiographic changes over time

Document adverse effects:

  • GI side effects from phosphate supplements
  • Evidence of hyperparathyroidism or nephrocalcinosis
  • Compliance challenges with multiple daily dosing

Monitor disease progression:

  • New fractures or pseudofractures
  • Worsening bone deformities
  • Declining quality of life measures

When to Resubmit

Clinical triggers for resubmission:

  • Documented treatment failure after 6-month adequate trial
  • Development of significant adverse effects
  • Disease progression despite conventional therapy
  • New clinical evidence supporting Crysvita use

Administrative triggers:

  • Plan formulary changes
  • New clinical guidelines favoring burosumab
  • Appeals success setting precedent

Appeals Playbook for Humana in Pennsylvania

Medicare Advantage Members

Pennsylvania's Independent External Review does NOT apply to Medicare plans. Humana Medicare members must follow federal Medicare appeals processes:

Level 1: Plan Internal Appeal (Redetermination)

  • File within 65 days of denial notice
  • Submit via Humana member portal or mail
  • Decision timeline: 7 calendar days for Part D redetermination

Level 2: Independent Review

  • File within 180 days if Level 1 denied
  • Qualified Independent Contractor (QIC) review
  • Decision timeline: 7 calendar days standard, 72 hours expedited

Expedited appeals available when delay could seriously jeopardize health; requires physician certification.

Commercial Humana Members

Pennsylvania's Independent External Review applies after internal appeals:

Internal Appeal First

  • Must exhaust Humana's internal process
  • Obtain "Final Adverse Benefit Determination" letter
  • Timeline varies by plan type

External Review Request

Success rates: Pennsylvania reported 50% overturn rate in 2024, with 259 out of 517 appeals resulting in coverage.

Required Documentation for Appeals

Medical records package:

  • Complete XLH diagnostic workup
  • Treatment history and failure documentation
  • Current symptoms and functional impact
  • Prescriber's detailed medical necessity letter

Administrative documents:

  • Original denial letter
  • All prior authorization submissions
  • Insurance policy documentation
  • Correspondence with Humana
Tip: For urgent situations requiring expedited review, include physician certification that delay poses serious risk to health or life.

FAQ

How long does Humana prior authorization take for Crysvita in Pennsylvania? Standard review takes 72 hours; expedited decisions within 24-48 hours for urgent cases. Electronic submissions through provider portals typically receive 1-business-day decisions per Humana's 2026 targets.

What if Crysvita is non-formulary on my Humana plan? Request a formulary exception with medical necessity documentation. Your prescriber must demonstrate that covered alternatives would be less effective or cause adverse effects for your specific condition.

Can I request an expedited appeal if my Crysvita is denied? Yes, if delay could seriously jeopardize your health. Medicare members file expedited appeals through federal process; commercial members can request expedited external review in Pennsylvania with physician certification.

Does Pennsylvania's external review apply to Humana Medicare plans? No. Medicare plans (including Humana Medicare Advantage) use federal appeals processes only. Pennsylvania's Independent External Review applies to commercial, marketplace, and fully-insured employer plans.

What counts as treatment failure for switching to Crysvita? Documented inadequate response to conventional phosphate plus calcitriol therapy after 3-6 months, evidenced by persistent hypophosphatemia, ongoing symptoms (bone pain, fractures), or radiographic progression of rickets/osteomalacia.

How much does Crysvita cost without insurance? Cash prices range from approximately $4,000-$40,000+ per vial depending on strength (10-60 mg). Annual costs vary significantly based on patient weight and dosing frequency (every 2-4 weeks).

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform ingests denial letters, plan policies, and clinical notes, then identifies the denial basis and drafts point-by-point rebuttals aligned to the plan's own rules, incorporating the right citations and clinical facts that payers expect.

For Pennsylvania residents facing Humana denials, understanding both state and federal appeals processes—and knowing which applies to your specific plan type—can mean the difference between paying thousands out-of-pocket or receiving covered treatment. Whether you're pursuing conventional alternatives or fighting for Crysvita coverage, proper documentation and strategic appeals can significantly improve your chances of success.

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 plan directly for personalized guidance. For assistance with complex appeals in Pennsylvania, contact the Pennsylvania Insurance Department's Office of Consumer Services or consider working with Counterforce Health for specialized appeals support.

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