By Counterforce Health Team in Voxzogo (vosoritide) —

How to Get Voxzogo (vosoritide) Approved by UnitedHealthcare in Virginia: Complete Prior Authorization Guide

Answer Box: Getting Voxzogo Covered by UnitedHealthcare in Virginia

UnitedHealthcare requires prior authorization for Voxzogo (vosoritide) in children under 18 with confirmed achondroplasia and open growth plates. The fastest path: have your pediatric endocrinologist or geneticist submit the PA Medical Necessity form via the OptumRx Provider Portal with genetic testing confirmation, bone age imaging, and growth velocity data. If denied, Virginia's external review process through the State Corporation Commission can overturn decisions within 45 days.

Start today: Call BioMarin RareConnections at 1-833-869-9646 for PA support and bridge therapy assistance.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather What You Need
  4. Submit the Prior Authorization Request
  5. Follow-Up and Tracking
  6. Typical Timelines in Virginia
  7. If You're Asked for More Information
  8. If You're Denied: Appeals Process
  9. Renewal and Reauthorization
  10. Quick Reference Checklist

What This Guide Covers

This guide helps Virginia families navigate UnitedHealthcare's prior authorization process for Voxzogo (vosoritide), the first FDA-approved medication for achondroplasia. Whether you're starting the initial approval process or appealing a denial, we'll walk through each step with specific forms, timelines, and Virginia-specific appeal rights.

Voxzogo can cost approximately $320,000 annually before insurance coverage, making proper authorization crucial for accessing this growth-promoting therapy for children with achondroplasia.

Before You Start: Verify Your Coverage

Check Your Plan Type

UnitedHealthcare offers different plan types in Virginia with varying requirements:

  • Commercial/Employer plans: Standard PA process through OptumRx
  • Medicare Advantage: May have additional step therapy requirements
  • Medicaid managed care: Different formulary and PA criteria may apply

Confirm In-Network Status

Ensure your prescribing specialist is in-network with UnitedHealthcare. Key Virginia providers include:

  • UVA Health (Charlottesville): Pediatric Endocrinology and Genetics
  • Inova Children's Hospital (Northern VA): Dr. Oksana Lazareva, Medical Director
  • Children's Hospital of The King's Daughters (Norfolk)
  • Carilion Children's Hospital (Roanoke)

Contact your provider's office to verify current UnitedHealthcare network participation.

Formulary Status

Voxzogo is classified as a Tier 4 specialty medication on UnitedHealthcare formularies, requiring prior authorization and limiting supplies to 30-day fills.

Gather What You Need

Essential Documentation

Medical Records:

  • Confirmed achondroplasia diagnosis with FGFR3 genetic testing results
  • Current growth charts showing annualized growth velocity
  • Recent bone age X-ray (hand/wrist) confirming open epiphyses
  • Height and weight measurements with percentile data

Clinical Information:

  • ICD-10 diagnosis code: Q77.4 (Achondroplasia)
  • Documentation that patient is under 18 years old
  • Medical necessity letter from pediatric endocrinologist or geneticist
  • Confirmation of no limb-lengthening surgery in past 18 months

Prescriber Requirements:

  • Must be a clinical geneticist, pediatric endocrinologist, or achondroplasia specialist
  • Current medical license and DEA number
  • Practice address and NPI number
Tip: BioMarin RareConnections provides PA form completion assistance and can help gather required documentation. Call 1-833-869-9646 for support.

Submit the Prior Authorization Request

Preferred Submission Method

OptumRx Provider Portal offers the fastest processing and real-time tracking. Healthcare providers can:

  1. Log into the OptumRx Provider Portal
  2. Upload medical records electronically
  3. Track submission status in real-time
  4. Receive automated notifications on decision status

Required Forms

UnitedHealthcare uses two potential forms for Voxzogo:

  1. PA Medical Necessity Form - Full criteria review requiring all documentation listed above
  2. PA Notification Form - Streamlined process requiring only achondroplasia diagnosis, age under 18, and open epiphyses

Clean Submission Checklist

  • Completed PA form with all required fields
  • FGFR3 genetic testing report
  • Bone age imaging (within 6-12 months)
  • Growth velocity data and charts
  • Medical necessity letter
  • Prescriber attestation and credentials
  • Insurance verification and member ID

Follow-Up and Tracking

When to Call

Contact UnitedHealthcare if you don't receive a decision within:

  • Standard requests: 15 business days
  • Urgent requests: 72 hours

Sample Call Script

"Hello, I'm calling to check the status of a prior authorization request for Voxzogo for [patient name], member ID [number]. The request was submitted on [date] by Dr. [name]. Can you provide the current status and reference number?"

Document everything: Note the date, time, representative name, and reference number for all calls.

Typical Timelines in Virginia

Standard Processing Times

UnitedHealthcare must respond to prior authorization requests within:

  • Commercial plans: 15 business days for standard requests
  • Urgent requests: 72 hours when medical urgency is documented
  • Medicare Advantage: 14 calendar days (7 days for expedited)

What Speeds Decisions

  • Complete documentation on first submission
  • Electronic submission via provider portal
  • Clear medical necessity justification
  • Specialist prescriber credentials

What Slows Decisions

  • Missing FGFR3 genetic testing
  • Incomplete growth velocity data
  • Non-specialist prescriber
  • Manual fax submissions requiring data entry

If You're Asked for More Information

Common Requests

Information Requested How to Respond Timeline
Additional growth data Submit 6-12 months of height/weight measurements 5 business days
Bone age confirmation Provide recent hand/wrist X-ray report 3 business days
Specialist consultation Schedule with pediatric endocrinologist 2-3 weeks
Genetic testing Order FGFR3 mutation analysis if not done 2-4 weeks
Note: UnitedHealthcare typically allows 14 days to submit additional information before making a final determination.

If You're Denied: Appeals Process

Understanding Your Denial

Common denial reasons include:

  • Missing genetic confirmation: FGFR3 testing not provided
  • Age criteria: Patient over 18 or under 2 years (depending on plan)
  • Closed growth plates: Bone age showing epiphyseal closure
  • Non-specialist prescriber: Requires pediatric endocrinologist or geneticist

Internal Appeals with UnitedHealthcare

First-Level Appeal:

  • File within 180 days of denial notice
  • Submit via member portal or mail to address on denial letter
  • Include denial letter, medical records, and physician appeal letter
  • Decision within 30 days (15 days for urgent)

Second-Level Appeal (if available):

  • File within 60 days of first-level denial
  • Same submission process and timeline

Virginia External Review Process

After exhausting internal appeals, Virginia residents can request external review through the State Corporation Commission Bureau of Insurance.

Filing Requirements:

  • Submit Form 216-A (External Review Request) within 120 days of final internal denial
  • Mail to: Virginia SCC Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218
  • Include all denial notices, medical records, and physician statements

Timeline:

  • Standard review: 45 days
  • Expedited review: 72 hours (urgent medical necessity) or 6 business days (investigational treatment)

Contact for Assistance:

  • Phone: 1-877-310-6560
  • Email: [email protected]
Important: Virginia's external review decision is final and binding on UnitedHealthcare. If approved, coverage must begin within 1-3 days.

Renewal and Reauthorization

Annual Renewal Requirements

UnitedHealthcare authorizes Voxzogo for 12 months at a time. Begin renewal 60-90 days before expiration with:

  • Updated growth velocity data showing positive response
  • Recent bone age imaging confirming open epiphyses
  • Current height/weight measurements
  • Physician assessment of continued medical necessity

Reauthorization Criteria

All of the following must be documented:

  • Documented positive response (improved annualized growth velocity vs. baseline)
  • Persistent open epiphyses on imaging
  • Continued achondroplasia diagnosis
  • No adverse events requiring discontinuation

Clinician Corner: Medical Necessity Letter

Healthcare providers should include these elements in medical necessity documentation:

Patient Background:

  • Confirmed achondroplasia diagnosis with FGFR3 mutation
  • Current age and growth parameters
  • Bone age and growth plate status

Clinical Rationale:

  • FDA approval for achondroplasia in pediatric patients ≥2 years
  • Expected benefit based on clinical trial data
  • Growth velocity goals and monitoring plan

Supporting Evidence:

  • Reference to FDA prescribing information
  • Clinical trial data showing improved annualized growth velocity
  • Professional society guidelines supporting treatment

Quick Reference Checklist

Before Starting

  • Verify UnitedHealthcare coverage and provider network status
  • Confirm achondroplasia diagnosis with genetic testing
  • Ensure prescriber is pediatric endocrinologist or geneticist
  • Document open growth plates with recent bone age imaging

During Submission

  • Use OptumRx Provider Portal for fastest processing
  • Submit complete documentation package
  • Obtain submission confirmation and reference number
  • Set calendar reminder for follow-up

If Denied

  • Review denial reason carefully
  • File internal appeal within 180 days
  • Prepare for Virginia external review if needed
  • Contact BioMarin RareConnections for bridge therapy

For Renewals

  • Start process 60-90 days before expiration
  • Document positive growth response
  • Confirm continued open growth plates
  • Update all clinical measurements

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals through targeted, evidence-backed strategies. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, pulling the right clinical evidence and procedural documentation for each case. Learn more about our prior authorization and appeals support at CounterforceHealth.org.

FAQ

How long does UnitedHealthcare prior authorization take for Voxzogo in Virginia? Standard requests receive decisions within 15 business days, while urgent requests are processed within 72 hours when medical necessity is documented.

What if Voxzogo is non-formulary on my UnitedHealthcare plan? Voxzogo is typically covered as a Tier 4 specialty medication. If listed as non-formulary, request a formulary exception with medical necessity documentation.

Can I request an expedited appeal in Virginia? Yes, Virginia allows expedited external review for urgent medical conditions that could seriously jeopardize health if delayed. The decision timeline is 72 hours for urgent medical necessity.

Does step therapy apply to Voxzogo? UnitedHealthcare typically doesn't require step therapy for Voxzogo since it's the only FDA-approved medication for achondroplasia. However, plans may require documentation that supportive care has been insufficient.

What support is available during coverage gaps? BioMarin RareConnections provides bridge therapy for eligible patients with active insurance appeals or coverage pursuits. Call 1-833-869-9646 for assistance.

How much does Voxzogo cost without insurance in Virginia? The annual list price is approximately $320,000 before insurance coverage. BioMarin offers copay assistance up to $18,200 annually for eligible commercial patients.

Sources & Further Reading

Disclaimer: This guide provides educational information about insurance coverage processes and should not be considered medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance plan directly for coverage determinations. For assistance with Virginia insurance appeals, contact the State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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