By Counterforce Health Team in Crysvita (burosumab) —

How to Get Crysvita (burosumab) Covered by UnitedHealthcare in Ohio: Complete Forms, Appeals, and Contact Guide

Answer Box: Getting Crysvita Covered in Ohio

UnitedHealthcare requires prior authorization for Crysvita (burosumab) through OptumRx for X-linked hypophosphatemia (XLH) and tumor-induced osteomalacia. Submit via the UnitedHealthcare Provider Portal with genetic testing, low serum phosphorus labs, and specialist prescription. If denied, you have 180 days for internal appeals, then external review through Ohio Department of Insurance at 1-800-686-1526. First step today: Verify your plan's formulary status and gather XLH diagnosis documentation.

Table of Contents

  1. Start Here: Verify Your Plan & Find Forms
  2. Required Forms & Documentation
  3. Submission Portals & Online Tools
  4. Fax Numbers & Mailing Addresses
  5. Specialty Pharmacy Enrollment
  6. Support Phone Lines & Contacts
  7. Ohio Appeals & External Review
  8. When to Update Your Resources

Start Here: Verify Your Plan & Find Forms

Before starting your Crysvita prior authorization, confirm your UnitedHealthcare plan covers this specialty medication. Crysvita appears on most UnitedHealthcare formularies but requires prior authorization across commercial, Medicare, and Medicaid plans.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all plans UHC Provider Portal
Formulary Status Covered but restricted Plan-specific formulary document
Step Therapy May apply for adults OptumRx PA policy
Specialty Pharmacy Optum Specialty only Post-approval enrollment
Age Limits ≥6 months (XLH), ≥2 years (TIO) FDA prescribing information
Tip: Call the member services number on your insurance card first to confirm your specific plan's coverage and any recent policy changes.

Required Forms & Documentation

UnitedHealthcare uses the OptumRx General Prior Authorization Form for Crysvita requests. The form version updates periodically, so always download the current version from the provider portal.

Essential Documentation Checklist

For X-linked Hypophosphatemia (XLH):

  • ✅ Genetic testing results confirming XLH mutation
  • ✅ Elevated FGF23 levels
  • ✅ Low fasting serum phosphorus (within 3 months)
  • ✅ Endocrinologist or metabolic bone specialist prescription
  • ✅ For adults: documented failure of oral phosphate + calcitriol therapy

For Tumor-Induced Osteomalacia (TIO):

  • ✅ Confirmed FGF23-related hypophosphatemia
  • ✅ Documentation that tumor is not resectable or localizable
  • ✅ Specialist evaluation and treatment plan

Medical Necessity Letter Components

Your prescribing physician should include these elements in their letter of medical necessity:

  1. Patient diagnosis with ICD-10 codes (E83.31 for familial hypophosphatemia)
  2. Clinical presentation including bone pain, fractures, or growth issues
  3. Laboratory evidence of phosphate wasting and elevated FGF23
  4. Prior treatment history and why alternatives failed or are contraindicated
  5. Treatment goals and monitoring plan
  6. Dosing rationale based on patient weight and clinical response

Submission Portals & Online Tools

UnitedHealthcare Provider Portal

The fastest way to submit Crysvita prior authorization requests is through the UnitedHealthcare Provider Portal using your One Healthcare ID.

Portal Access Steps:

  1. Go to uhcprovider.com
  2. Sign in with One Healthcare ID (multifactor authentication required)
  3. Select "Prior Authorization & Notification"
  4. Choose "Specialty Pharmacy Transactions" for medical benefit drugs
  5. Upload all supporting documentation electronically

Processing Timelines:

  • Standard review: 15 business days
  • Urgent review: 72 hours (call 1-800-711-4555 for urgent requests)
  • Status tracking available through portal
Note: The portal automatically checks if prior authorization is required for your specific member and drug combination.

For Patients: Member Portal Access

Patients can track their prior authorization status through the UnitedHealthcare member portal or mobile app. You'll need your member ID and can view:

  • PA request status
  • Required additional documentation
  • Appeal deadlines and options
  • Pharmacy benefit details

Fax Numbers & Mailing Addresses

While online submission is preferred, UnitedHealthcare accepts prior authorization requests via fax for non-urgent cases.

OptumRx Prior Authorization Contacts

  • Non-urgent PA requests: Fax to 1-844-403-1027
  • Urgent requests (72-hour review): Call 1-800-711-4555
  • Mailing address: Use provider portal for current address (verify with source linked below)

Cover Sheet Tips:

  • Include member ID, drug name (Crysvita/burosumab), and prescriber NPI
  • Mark "URGENT" clearly if expedited review is needed
  • Number all pages and include total page count
  • Include return fax number for questions

Specialty Pharmacy Enrollment

Once Crysvita receives prior authorization approval, the medication must be dispensed through Optum Specialty Pharmacy. This is a mandatory requirement for all UnitedHealthcare plans.

Enrollment Process

  1. Provider sends prescription to Optum Specialty after PA approval
  2. Patient enrollment call: Optum contacts patient at 1-855-427-4682
  3. Clinical assessment: Pharmacist reviews diagnosis and treatment plan
  4. Delivery coordination: Schedule home delivery or clinic shipment
  5. Administration training: For patients self-injecting at home
  6. Ongoing monitoring: Adherence tracking and side effect management

What Optum Specialty Provides

  • Clinical pharmacist consultations
  • Injection training and supplies
  • Refrigerated medication delivery
  • Insurance coordination and copay assistance
  • 24/7 clinical support hotline

Support Phone Lines & Contacts

For Providers

  • General provider services: Use number on provider portal after login
  • PA status and appeals: 1-800-711-4555
  • Peer-to-peer reviews: Request through provider portal or call above number
  • Technical portal support: Available through portal chat feature

For Patients and Caregivers

  • Member services: Number on your insurance card
  • OptumRx specialty support: 1-855-427-4682
  • Appeals assistance: Use member portal or call member services
  • Urgent clinical questions: Optum Specialty 24/7 hotline

What to Ask When You Call:

  • Current PA status and any missing documentation
  • Timeline for decision
  • Appeal rights and deadlines
  • Copay assistance program availability
  • Specialty pharmacy enrollment status

Ohio Appeals & External Review

If UnitedHealthcare denies your Crysvita prior authorization, Ohio provides strong consumer protection through a two-level appeals process.

Internal Appeals with UnitedHealthcare

Timeline: 180 days from denial notice How to submit: UnitedHealthcare member portal, fax, or mail Processing time: 30 days standard, 72 hours expedited Required documents:

  • Original denial letter
  • Updated clinical documentation
  • Physician statement on medical necessity
  • Any new lab results or imaging

Ohio External Review Process

After exhausting internal appeals, Ohio residents can request a free external review through the Ohio Department of Insurance.

Key Details:

  • Deadline: 180 days from final internal denial
  • Cost: Free to consumer
  • Contact: Ohio Department of Insurance at 1-800-686-1526
  • Processing: 30 days standard, 72 hours expedited
  • Decision: Binding on insurer if coverage approved

How to Request External Review:

  1. Call ODI consumer hotline at 1-800-686-1526
  2. Explain your UnitedHealthcare Crysvita denial
  3. ODI will check eligibility and provide guidance
  4. Submit required forms and documentation
  5. Independent medical experts review your case
Important: Self-funded employer plans may follow federal ERISA rules instead of Ohio's external review process. ODI can help determine which process applies to your plan.

Counterforce Health specializes in helping patients navigate complex prior authorization and appeals processes for specialty medications like Crysvita. Our platform analyzes denial letters and creates targeted, evidence-backed appeals that address payer-specific requirements and clinical criteria.

When to Update Your Resources

UnitedHealthcare and OptumRx update their policies, forms, and contact information regularly. Check for updates:

Quarterly Reviews

  • Download current PA forms from provider portal
  • Verify specialty pharmacy contact numbers
  • Check formulary status for plan year changes
  • Review any new step therapy requirements

Annual Policy Changes

  • January 1: New formularies take effect
  • Mid-year: Some policy updates for Medicare plans
  • Check Ohio DOI website for any appeals process changes

Immediate Updates Needed When:

  • You receive a denial citing outdated forms
  • Portal access issues or new authentication requirements
  • Changes in specialty pharmacy network
  • New clinical guidelines for XLH treatment

Best Practice: Bookmark the UnitedHealthcare Provider Portal and Ohio Department of Insurance consumer pages for the most current information.

Frequently Asked Questions

How long does UnitedHealthcare PA take for Crysvita in Ohio? Standard review takes 15 business days, but urgent requests can be processed within 72 hours if clinical justification is provided.

What if Crysvita is non-formulary on my plan? Even non-formulary drugs can be covered through formulary exceptions with strong medical necessity documentation and specialist support.

Can I request expedited appeals in Ohio? Yes, if a delay would seriously jeopardize your health. Both UnitedHealthcare internal appeals and Ohio external reviews offer expedited timelines.

Does step therapy apply if I've tried treatments outside Ohio? Yes, documented treatment failures from other states count toward step therapy requirements. Include all medical records in your PA submission.

What happens if Ohio external review denies my appeal? The decision is final for the external review process, but you retain rights to seek other remedies including legal action or regulatory complaints.

From our advocates: We've seen Crysvita approvals succeed when families gather comprehensive genetic testing results upfront and work closely with their endocrinologist to document all prior treatment attempts. The key is showing clear medical necessity through objective lab values and specialist expertise—this combination significantly improves approval odds.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on your specific plan terms and clinical circumstances. Always consult with your healthcare provider and insurance company for guidance on your individual situation.

For additional help with health insurance appeals in Ohio, contact the Ohio Department of Insurance at 1-800-686-1526 or visit their consumer assistance page.

Sources & Further Reading

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.