By Counterforce Health Team in Crysvita (burosumab) —

How to Get Crysvita (burosumab) Covered by UnitedHealthcare in Pennsylvania: Complete Guide with Forms, Appeals, and Contacts

Answer Box: Getting Crysvita Covered by UnitedHealthcare in Pennsylvania

UnitedHealthcare requires prior authorization for Crysvita (burosumab) in Pennsylvania. Submit through the UnitedHealthcare Provider Portal with required documentation: XLH diagnosis confirmation (genetic testing or elevated FGF23), specialist prescription, and for adults, evidence of failed oral phosphate/calcitriol therapy. If denied, use Pennsylvania's new external review program within four months—about 50% of appeals succeed. Start today: Verify your specific plan requirements and gather diagnostic documentation.

Table of Contents

  1. Start Here: Verify Your Plan
  2. Required Forms and Documentation
  3. Submission Portals and Methods
  4. Fax Numbers and Mail Addresses
  5. Specialty Pharmacy Requirements
  6. Support Lines and Contacts
  7. Pennsylvania External Review Process
  8. Common Denial Reasons and Solutions
  9. Appeals Playbook
  10. Costs and Patient Assistance
  11. FAQ

Start Here: Verify Your Plan

Before beginning the prior authorization process, confirm your specific UnitedHealthcare plan type and current policy requirements:

Plan Types in Pennsylvania:

  • Commercial/Employer plans
  • Individual marketplace plans (through Pennie)
  • Medicare Advantage
  • Medicaid Community Plan
Tip: Log into your UnitedHealthcare member portal at myuhc.com to verify your specific benefits and any recent policy updates.

Each plan type may have slightly different requirements and forms. The UnitedHealthcare Provider Portal contains Pennsylvania-specific information and current policies.

Required Forms and Documentation

Coverage Requirements for Crysvita

UnitedHealthcare covers Crysvita for two FDA-approved indications with specific criteria:

X-linked Hypophosphatemia (XLH):

  • Age ≥6 months
  • Confirmed diagnosis via genetic testing (PHEX mutation) OR elevated FGF23 levels
  • Prescription from or consultation with endocrinologist or nephrologist
  • For adults: documented failure of oral phosphate and calcitriol therapy
  • Low serum phosphorus laboratory results

Tumor-Induced Osteomalacia (TIO):

  • Age ≥2 years
  • Unresectable or unlocalized phosphaturic mesenchymal tumor
  • FGF23-related hypophosphatemia
  • Oral phosphate and vitamin D discontinued ≥2 weeks before starting Crysvita

Essential Documentation Checklist

  • Completed OptumRx General Prior Authorization Form
  • Medical records confirming diagnosis
  • Laboratory results (FGF23, serum phosphorus)
  • Genetic testing results (if applicable)
  • Prior treatment history and failure documentation
  • Specialist consultation notes
  • Letter of medical necessity
  • Signed attestation regarding concurrent therapies

The current UnitedHealthcare Community Plan policy (effective June 1, 2025) outlines specific requirements for Pennsylvania Medicaid members.

Submission Portals and Methods

Primary Submission Method: Provider Portal

UnitedHealthcare Provider Portal (preferred method):

  • Website: UHCprovider.com
  • Requires registered One Healthcare ID
  • Electronic submission for fastest processing
  • Real-time status tracking
  • Document upload capability

Portal Benefits:

  • Immediate confirmation of receipt
  • Faster processing (up to 15 business days standard, 72 hours urgent)
  • Direct communication for additional information requests
  • Appeals can be submitted through the same portal

Alternative Submission Methods

If portal access is unavailable, use these backup options:

  • Fax: 1-844-403-1027 (non-urgent requests)
  • Urgent review phone: 1-800-711-4555
Note: Electronic submission through the provider portal is strongly recommended for tracking and faster processing.

Fax Numbers and Mail Addresses

UnitedHealthcare Community Plan (Pennsylvania Medicaid)

Fax: 1-866-940-7328 Use for: Medical benefit prior authorization submissions

Pennsylvania Medical Assistance Program

Fax: 1-800-335-6093 Use for: State Medicaid program submissions Form: Pennsylvania DHS Crysvita PA form

Cover Sheet Tips

  • Include patient's full name and member ID
  • Mark "URGENT" if applicable for expedited review
  • List all attached documents
  • Include prescriber's NPI and contact information
  • Keep confirmation receipts

Specialty Pharmacy Requirements

Crysvita must be dispensed through specialty pharmacy networks. UnitedHealthcare typically uses OptumRx specialty pharmacy services.

Onboarding Steps:

  1. Prior authorization approval must be obtained first
  2. Prescription sent to designated specialty pharmacy
  3. Patient enrollment and benefits verification
  4. Coordination of delivery and administration training
  5. Ongoing monitoring and refill coordination

Key Contacts:

  • OptumRx Specialty: Contact through provider portal
  • Patient support services included with specialty pharmacy enrollment

Support Lines and Contacts

For Providers

UnitedHealthcare Provider Services:

  • General inquiries: 1-888-842-3211
  • Prior authorization status: Available through provider portal
  • Peer-to-peer review requests: 1-800-711-4555

For Members

UnitedHealthcare Customer Service:

  • Member services number on insurance card
  • Available 24/7 for coverage questions
  • Appeals assistance available

Pennsylvania-Specific Resources

Pennsylvania Insurance Department:

  • Consumer Services: 1-877-881-6388
  • Email: [email protected]
  • External review assistance and forms

Pennsylvania External Review Process

Pennsylvania launched its Independent External Review Program in January 2024, providing a state-supervised appeals process with impressive success rates.

Key Statistics

  • 50% success rate in first year of operation
  • 259 out of 517 appeals ruled in favor of patients
  • Coverage for treatments ranging from surgeries to expensive medications

Process Timeline

  1. Complete internal appeals with UnitedHealthcare first
  2. Receive Final Adverse Benefit Determination letter
  3. Submit external review request within 4 months
  4. Standard review: 45 days for decision
  5. Expedited review: 72 hours for urgent cases

How to Submit

Important: External review is binding on UnitedHealthcare. If approved, coverage must be provided immediately, including retroactive reimbursement.

Clinician Corner: Medical Necessity Letter

When writing a letter of medical necessity for Crysvita, include these essential elements:

Required Components:

  • Patient's specific diagnosis with ICD-10 codes
  • Clinical presentation and severity
  • Laboratory evidence (FGF23, phosphorus levels)
  • Prior treatments attempted and outcomes
  • Contraindications to alternative therapies
  • Expected treatment goals and monitoring plan
  • Dosing rationale based on FDA labeling

Supporting Evidence:

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Insufficient diagnostic evidence Submit genetic testing or FGF23 levels Lab reports, genetic counselor notes
Missing step therapy Document oral phosphate/calcitriol failure Treatment history, intolerance records
Concurrent therapy concerns Provide discontinuation attestation Prescriber statement, medication list
Quantity/dosing issues Justify based on FDA labeling Weight-based dosing calculation
Lack of specialist involvement Obtain endocrinologist consultation Specialist referral, consultation notes

Appeals Playbook

Internal Appeals with UnitedHealthcare

Level 1: Standard Appeal

  • Timeline: 180 days from denial to file
  • Processing: 15-30 days for decision
  • Method: Provider portal or written submission
  • Required: Original denial letter, additional clinical evidence

Level 2: Expedited Appeal

  • Timeline: 72 hours for urgent cases
  • Qualification: Immediate health risk
  • Method: Phone request to 1-800-711-4555
  • Required: Physician attestation of urgency

External Review (Pennsylvania)

Eligibility:

  • Completed all internal UnitedHealthcare appeals
  • Fully insured plans only (not self-funded ERISA plans)
  • Medical necessity or experimental treatment denials

Timeline:

  • File within: 4 months of final denial
  • Standard decision: 45 days
  • Expedited decision: 72 hours

Success Factors:

  • Complete medical records
  • Specialist support letters
  • Peer-reviewed evidence
  • Clear treatment necessity documentation

Costs and Patient Assistance

Manufacturer Support

Kyowa Kirin Patient Support:

  • Copay assistance programs
  • Patient access services
  • Insurance navigation support
  • Financial hardship programs

Additional Resources

  • Patient Advocate Foundation: Copay relief programs
  • National Organization for Rare Disorders (NORD): Financial assistance
  • State pharmaceutical assistance programs: Income-based support

Typical Costs

  • Annual treatment cost: $200,000-$400,000+ depending on patient weight
  • With insurance: Varies by plan, copay assistance may apply
  • Without coverage: Full retail price, patient assistance programs essential

At Counterforce Health, we help patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer-specific requirements, significantly improving approval rates for specialty medications like Crysvita.

FAQ

How long does UnitedHealthcare prior authorization take in Pennsylvania? Standard reviews take up to 15 business days, while urgent requests are processed within 72 hours. Electronic submissions through the provider portal typically process faster than fax submissions.

What if Crysvita is not on my formulary? Non-formulary medications can still be covered through medical necessity exceptions. Submit a comprehensive prior authorization with strong clinical justification and specialist support.

Can I request an expedited appeal? Yes, if there's immediate risk to health or life. Contact UnitedHealthcare at 1-800-711-4555 with physician documentation of urgency for 72-hour expedited review.

Does step therapy apply if I failed treatments in another state? Treatment history from other states should be accepted. Include complete medical records and provider attestations documenting prior therapy failures or intolerances.

What happens if my external review is approved? UnitedHealthcare must immediately provide coverage. If you paid out-of-pocket during the appeal process, you're entitled to reimbursement.

How do I know if I have a self-funded employer plan? Check your insurance card or employee benefits summary. Self-funded plans are governed by federal ERISA law and may not be eligible for Pennsylvania's external review process.

From our advocates: We've seen cases where patients initially denied for Crysvita gained approval after submitting comprehensive genetic testing results and detailed treatment failure documentation. The key is often providing complete diagnostic evidence and clear documentation of why alternative treatments aren't suitable. While outcomes vary, thorough preparation significantly improves approval chances.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements change frequently. Always verify current requirements with UnitedHealthcare and consult with your healthcare provider regarding treatment decisions. For personalized assistance with prior authorizations and appeals, consider working with experienced advocacy services like Counterforce Health.

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