By Counterforce Health Team in Voxzogo (vosoritide) —

How to Get Voxzogo (Vosoritide) Covered by Aetna CVS Health in Ohio: Complete 2025 Guide with Forms and Appeals

Answer Box: Getting Voxzogo (Vosoritide) Covered by Aetna CVS Health in Ohio

Aetna CVS Health covers Voxzogo for pediatric achondroplasia patients with open growth plates, requiring prior authorization from a pediatric endocrinologist, geneticist, or neurologist. The fastest path to approval: (1) Confirm FGFR3 mutation or clinical achondroplasia diagnosis with X-ray evidence, (2) Document open epiphyses through recent imaging, and (3) Submit complete PA request to CVS Caremark at 1-800-294-5979. Standard decisions take 30-45 days; expedited reviews complete within 72 hours for urgent cases. If denied, Ohio residents have 180 days to file external review through the Ohio Department of Insurance.

Table of Contents

  1. Start Here: Verify Your Plan and Find Forms
  2. Prior Authorization Requirements
  3. Forms and Submission Process
  4. CVS Specialty Pharmacy Enrollment
  5. Appeals Process in Ohio
  6. Contact Information and Support
  7. Common Denial Reasons and Solutions
  8. Frequently Asked Questions

Start Here: Verify Your Plan and Find Forms

Before requesting Voxzogo coverage, confirm you have an Aetna CVS Health plan that includes specialty pharmacy benefits. Most Aetna plans process specialty medications through CVS Caremark, but coverage criteria can vary by plan type.

First Steps:

  1. Check your member ID card for "CVS Caremark" or "CVS Health" branding
  2. Log into your Aetna member portal to verify specialty drug coverage
  3. Call Aetna Member Services at 1-800-872-3862 to confirm your plan's specialty pharmacy network
Note: Self-funded employer plans may have different coverage criteria than standard Aetna plans. Verify your specific plan's requirements before starting the PA process.

Coverage Requirements at a Glance

Requirement Details Documentation Needed
Diagnosis Confirmed achondroplasia FGFR3 genetic test OR clinical symptoms + X-ray findings
Growth Plates Must be open Imaging within 6 months showing open epiphyses
Age 2+ years old Birth certificate or medical records
Prescriber Qualified specialist Pediatric endocrinologist, geneticist, or neurologist
Dosing Weight-based calculation 0.24 mg/kg daily subcutaneous injection
Approval Period 12 months initial Renewal requires growth velocity data

Source: Aetna Voxzogo Policy 5069-A

Prior Authorization Requirements

Aetna CVS Health requires prior authorization for Voxzogo before dispensing. The medication is covered under specialty pharmacy benefits with specific clinical criteria that must be met.

Diagnostic Confirmation

Option 1: Genetic Testing (Preferred)

  • Laboratory report confirming pathogenic FGFR3 variant
  • Must specify the exact mutation (e.g., G380R, R248C)

Option 2: Clinical Diagnosis

  • Short stature with rhizomelia (shortened arms and legs)
  • Characteristic facial features
  • Trident hand configuration
  • X-ray findings consistent with achondroplasia

Growth Plate Documentation

Recent imaging (within 6 months) must confirm open epiphyses. Acceptable studies include:

  • X-rays of long bones
  • Bone age studies
  • Growth plate assessment by pediatric radiologist

Specialist Requirements

Prior authorization must be submitted by one of these qualified providers:

  • Pediatric endocrinologist (most common)
  • Geneticist with pediatric experience
  • Neurologist treating achondroplasia complications
Clinician Corner: Include baseline growth velocity measurements (cm/year) in your PA submission. Aetna requires this data for both initial approval and renewal decisions. Document height measurements from at least 6 months of pre-treatment monitoring.

Forms and Submission Process

Step-by-Step: Fastest Path to Approval

Step 1: Obtain PA Form

  • Call Aetna specialty PA line: 1-800-294-5979
  • Request current Voxzogo prior authorization form
  • Verify you have the 2024/2025 version (forms update annually)

Step 2: Complete Clinical Documentation

  • Genetic testing report or clinical assessment with X-rays
  • Growth plate imaging within 6 months
  • Baseline growth velocity data (height measurements over 6+ months)
  • Weight-based dosing calculation (0.24 mg/kg daily)

Step 3: Submit Complete Package

  • Fax completed form with all attachments
  • Include prescriber attestation of medical necessity
  • Ensure specialist credentials are clearly documented

Step 4: Follow Up

  • Standard review: 30-45 days
  • Expedited review: 72 hours (requires urgent medical justification)
  • Track status through Aetna provider portal

Required Documentation Checklist

  • Completed Aetna PA form
  • FGFR3 genetic test report OR clinical diagnosis with X-rays
  • Imaging confirming open growth plates (≤6 months old)
  • Specialist consultation notes
  • Baseline growth velocity measurements
  • Weight-based dosing calculations
  • Insurance card and patient demographics

CVS Specialty Pharmacy Enrollment

Once Aetna approves your PA, Voxzogo must be dispensed through CVS Specialty Pharmacy. The enrollment process typically begins automatically after approval.

Enrollment Steps

  1. Initial Contact: CVS Specialty will call within 24-48 hours of PA approval
  2. Patient Interview: Verify insurance, shipping address, and injection training needs
  3. Delivery Setup: Choose home or clinic delivery (1-2 days after enrollment)
  4. Ongoing Support: Assigned CareTeam member for refills and questions

CVS Specialty Contact Information

Tip: You're not required to use CVS Specialty if another in-network specialty pharmacy can provide Voxzogo. However, CVS typically offers the most streamlined process for Aetna members.

Appeals Process in Ohio

If Aetna denies your Voxzogo PA request, Ohio residents have robust appeal rights through both internal insurance company reviews and external state oversight.

Internal Appeals with Aetna

Level 1: Standard Appeal

  • Timeline: File within 180 days of denial notice
  • Decision: 30-45 days for standard review
  • Submission: Include denial letter, clinical records, and rebuttal letter

Level 2: Expedited Appeal

  • Timeline: Available if delay would jeopardize health
  • Decision: 72 hours
  • Requirements: Physician certification of urgency

Ohio External Review Process

If Aetna upholds the denial after internal appeals, Ohio law provides independent external review through the Ohio Department of Insurance.

External Review Timeline

  • Filing Deadline: 180 days from final Aetna denial
  • Standard Review: 30 days for decision
  • Expedited Review: 72 hours (urgent cases only)
  • Cost: Free to patients

How to File External Review

  1. Contact Ohio Department of Insurance: 1-800-686-1526
  2. Request external review application form
  3. Submit completed form with all denial letters and clinical records
  4. ODI randomly assigns qualified Independent Review Organization (IRO)
Important: External review decisions are binding on Aetna. If the IRO overturns the denial, Aetna must provide coverage.

Contact Information and Support

Aetna CVS Health Contacts

Purpose Phone Number Hours
Member Services 1-800-872-3862 24/7
Prior Authorization 1-800-294-5979 Business hours
CVS Specialty 1-800-237-2767 7:30 AM-9 PM ET, M-F
Appeals 1-877-848-5855 Business hours

Ohio State Resources

  • Ohio Department of Insurance Consumer Hotline: 1-800-686-1526
  • External Review Information: insurance.ohio.gov
  • UHCAN Ohio (Consumer advocacy): Provides free assistance with insurance appeals

Manufacturer Support

BioMarin RareConnections

  • Phone: 1-866-906-6100
  • Services: PA support, copay assistance, clinical resources
  • Coverage Authorization Guide: Available to healthcare providers

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies, then drafts point-by-point rebuttals aligned to payer-specific requirements, pulling the right clinical evidence and procedural details to maximize approval chances.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Missing genetic confirmation Submit FGFR3 test results Laboratory report with specific variant
Closed growth plates Provide recent imaging X-rays or bone age study ≤6 months
Non-specialist prescriber Transfer to qualified provider Pediatric endocrinologist, geneticist, or neurologist
Insufficient growth data Document baseline measurements Height tracking over 6+ months
Not medically necessary Submit comprehensive clinical justification Growth velocity data, treatment goals, specialist assessment

Appeal Letter Template Points

When writing an appeal for Voxzogo denial, address these key elements:

  1. FDA Approval Status: Voxzogo is FDA-approved for achondroplasia in pediatric patients ≥2 years with open epiphyses
  2. No Alternative Treatments: Voxzogo is the only FDA-approved pharmacologic treatment for achondroplasia
  3. Clinical Evidence: Reference FDA approval based on improved annualized growth velocity
  4. Plan Consistency: Cite Aetna's own coverage policy criteria that the patient meets
  5. Medical Necessity: Document how treatment aligns with standard of care guidelines

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take for Voxzogo in Ohio? Standard PA decisions take 30-45 days from submission. Expedited reviews are completed within 72 hours when a physician certifies that delay would jeopardize the patient's health.

What if Voxzogo is not on my Aetna formulary? You can request a formulary exception with supporting clinical documentation. Aetna must respond within 72 hours for urgent requests. If denied, the standard appeals process applies.

Can I request an expedited appeal in Ohio? Yes, expedited appeals are available when your physician certifies that applying standard timeframes may seriously jeopardize your health. Both Aetna internal appeals and Ohio external reviews offer expedited options.

Does step therapy apply to Voxzogo? No, step therapy typically doesn't apply since Voxzogo is the only FDA-approved pharmacologic treatment for achondroplasia. However, some plans may require documentation of supportive care measures.

What happens if I move out of Ohio during treatment? Your Aetna coverage continues, but appeal rights may change based on your new state's insurance laws. Contact Aetna Member Services to understand any differences in your new location.

How much does Voxzogo cost with Aetna coverage? Costs vary by plan design. Typical specialty medication copays range from $50-500 per month. BioMarin offers copay assistance programs that may reduce out-of-pocket costs significantly.

Can my pediatrician prescribe Voxzogo? Aetna requires prescriptions from pediatric endocrinologists, geneticists, or neurologists. Your pediatrician can refer you to a qualified specialist for Voxzogo management.

What if genetic testing shows I don't have an FGFR3 mutation? You may still qualify if you have clinical symptoms of achondroplasia with supporting X-ray findings. However, genetic confirmation provides the strongest evidence for coverage approval.

Counterforce Health's platform helps turn insurance denials into successful appeals by analyzing payer policies and crafting evidence-backed rebuttals. Learn more about getting prescription drugs approved at www.counterforcehealth.org.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage decisions depend on individual plan benefits and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific coverage determinations. For personalized assistance with Ohio insurance appeals, contact the Ohio Department of Insurance Consumer Services at 1-800-686-1526.

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