How to Get Voxzogo (vosoritide) Covered by Aetna (CVS Health) in Texas: Complete 2025 Guide with Forms and Appeals
Answer Box: Getting Voxzogo (vosoritide) Covered by Aetna (CVS Health) in Texas
Eligibility: Children ≥2 years with achondroplasia, open growth plates, and specialist care. Fastest path: Submit complete prior authorization with genetic test, growth plate imaging, and specialist letter. Start today: Call Aetna specialty PA line at 1-800-294-5979 for current forms, then gather FGFR3 test results and recent bone age X-rays. If denied, Texas law provides internal appeals (180 days) and external review through Independent Review Organizations (IROs) with binding decisions.
Table of Contents
- Coverage Requirements at a Glance
- Step-by-Step: Fastest Path to Approval
- Required Documentation Checklist
- Common Denial Reasons & How to Fix Them
- Appeals Process in Texas
- Cost Assistance and Support Programs
- When to Escalate to External Review
- FAQ
Coverage Requirements at a Glance
| Requirement | What It Means | Where to Find It | Source |
|---|---|---|---|
| Prior Authorization | Mandatory before first fill | Aetna specialty PA line | Aetna Voxzogo Policy 5069-A |
| Age Requirement | ≥2 years with open epiphyses | Birth certificate + bone age X-ray | FDA Label |
| Genetic Confirmation | FGFR3 pathogenic variant OR clinical diagnosis | Lab report or detailed clinical assessment | Aetna Policy |
| Specialist Prescriber | Endocrinologist, geneticist, or neurologist | Provider credentials | Aetna Policy |
| Growth Data | ≥6 months baseline growth velocity | Growth charts from clinic visits | BioMarin Coverage Guide |
| Specialty Pharmacy | Must use CVS Specialty | Prescription routing | CVS Specialty |
Step-by-Step: Fastest Path to Approval
1. Verify Coverage and Get Forms
Who: Patient/family
Action: Call Aetna member services (number on ID card) and specialty PA line at 1-800-294-5979
Timeline: Same day
Get: Current Voxzogo PA form for your specific plan and confirmation of formulary status
2. Confirm Specialist Care
Who: Family
Action: Ensure prescriber is pediatric endocrinologist, clinical geneticist, or neurologist
Timeline: May require referral (2-4 weeks)
Texas Options: Texas Children's Hospital Skeletal Dysplasia Program, Children's Health Metabolic Bone Clinic
3. Gather Required Documentation
Who: Clinic staff + family
Action: Collect genetic test, bone age X-ray, growth data, specialist notes
Timeline: 1-2 weeks if recent; longer if tests needed
Critical: Ensure bone age shows open growth plates within 6 months
4. Complete Prior Authorization
Who: Prescriber's office
Action: Submit complete PA packet via Aetna provider portal or fax
Timeline: Same day submission
Include: All items from documentation checklist
5. Track Decision
Who: Clinic + family
Action: Follow up with Aetna if no response in 5-7 business days
Timeline: Standard PA decisions in 30-45 days; expedited in 72 hours
Next Step: If approved, CVS Specialty contacts family; if denied, proceed to appeals
6. Enroll in Manufacturer Support
Who: Family
Action: Contact BioMarin RareConnections at 1-866-906-6100
Timeline: Can start during PA process
Benefits: Coverage support, co-pay assistance, injection training
7. Begin Treatment
Who: Family + CVS Specialty
Action: Coordinate home delivery and injection training
Timeline: 24-48 hours after PA approval
Ongoing: Regular monitoring with specialist for growth velocity and safety
Required Documentation Checklist
✅ Completed Aetna Voxzogo PA form (current year version)
✅ Genetic confirmation: FGFR3 lab report OR detailed clinical assessment with X-ray findings
✅ Bone age X-ray (within 6 months) showing open growth plates
✅ Growth data: Height measurements over ≥6 months with calculated growth velocity
✅ Specialist consultation note documenting diagnosis, treatment rationale, and medical necessity
✅ Current weight and dose calculation (0.24 mg/kg/day subcutaneous)
✅ Birth certificate or age documentation
✅ Prescriber credentials showing specialty certification
✅ Signed medical necessity attestation
Tip: Incomplete packets are the most common cause of delays. Have your specialist's office review this checklist before submission.
Common Denial Reasons & How to Fix Them
| Denial Reason | How to Overturn | Required Documents |
|---|---|---|
| "Diagnosis not confirmed" | Submit complete genetic report OR detailed clinical/radiographic assessment | FGFR3 test result or X-ray with clinical description |
| "Growth plates closed" | Provide recent bone age X-ray with radiologist interpretation | Bone age study ≤6 months old |
| "Insufficient growth data" | Calculate and document baseline growth velocity over ≥6 months | Growth chart with velocity calculation |
| "Non-specialist prescriber" | Transfer care to pediatric endocrinologist or geneticist | Specialist consultation note |
| "Not medically necessary" | Emphasize FDA approval, lack of alternatives, growth optimization goals | Medical necessity letter citing policy criteria |
Appeals Process in Texas
Internal Appeal (First Level)
- Deadline: 180 days from denial letter
- Submit to: Aetna appeals department (address on denial letter)
- Timeline: 30 days for standard; 72 hours for expedited
- Include: Additional documentation addressing denial reasons, updated specialist letter
External Review (Texas IRO)
- When: After internal appeal denial for medical necessity disputes
- Form: TDI Form LHL009
- Timeline: 20 days standard; 3 days for life-threatening conditions
- Binding: Yes, insurer must comply if overturned
- Cost: Free to patient
Note: For ongoing treatment denials or life-threatening conditions, you may request immediate external review without internal appeal first.
Texas Department of Insurance Contact:
Consumer Help Line: 1-800-252-3439
IRO Information
Cost Assistance and Support Programs
BioMarin RareConnections
- Eligibility: Commercial insurance (including Aetna)
- Benefits: Co-pay assistance, coverage navigation, injection training
- Contact: 1-866-906-6100
- Website: biomarin-rareconnections.com
CVS Specialty Pharmacy Services
- Included: Home delivery, clinical support, insurance coordination
- Contact: Automatic enrollment after PA approval
- Benefits: 24/7 pharmacist support, injection training resources
Important: Co-pay assistance not available for government insurance (Medicaid, Medicare, TRICARE).
When to Escalate to External Review
Consider Texas IRO external review when:
- Internal appeal denied based on "medical necessity" or "experimental" determination
- Aetna claims treatment doesn't meet policy criteria despite meeting all requirements
- Delay in treatment could affect growth potential during limited window
- Specialist confirms all clinical criteria are met
Counterforce Health helps patients navigate complex insurance denials by turning rejection letters into targeted, evidence-backed appeals. Our platform identifies the specific denial basis and drafts point-by-point rebuttals aligned to each plan's own rules, pulling the right citations and clinical facts to strengthen your case. Learn more at counterforcehealth.org.
FAQ
Q: How long does Aetna prior authorization take in Texas?
A: Standard PA decisions take 30-45 days. Expedited requests (when delay could jeopardize health) are decided within 72 hours.
Q: What if Voxzogo isn't on my Aetna formulary?
A: Request a formulary exception with your PA submission. Include medical necessity letter explaining lack of alternatives and FDA approval status.
Q: Can I start treatment while appealing?
A: Generally no, unless you pay out-of-pocket. However, for urgent situations, request expedited review and ask about continuation of care policies.
Q: Does step therapy apply to Voxzogo?
A: No FDA-approved alternatives exist for achondroplasia, so step therapy typically doesn't apply. If required, document this in your appeal.
Q: What specialists can prescribe Voxzogo in Texas?
A: Pediatric endocrinologists, clinical geneticists, or neurologists. Texas Children's Hospital and Children's Health Dallas have experienced providers.
Q: How much does Voxzogo cost without insurance?
A: List price approximately $320,000 annually. With BioMarin co-pay assistance and insurance coverage, out-of-pocket costs are typically much lower.
Q: Can I appeal to someone outside Aetna?
A: Yes, Texas law provides Independent Review Organization (IRO) external review for medical necessity denials. The decision is binding on Aetna.
Q: What if my child's growth plates are closing soon?
A: Request expedited PA and appeal processes. Document urgency in specialist letter, as treatment window is limited to when growth plates remain open.
Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Treatment decisions should be made in consultation with qualified healthcare providers. For official appeals guidance, contact the Texas Department of Insurance at 1-800-252-3439.
When facing a complex denial, Counterforce Health specializes in transforming insurance rejections into successful appeals by identifying specific denial reasons and crafting evidence-based responses that align with each payer's own policies and criteria.
Sources & Further Reading
- Aetna Voxzogo Clinical Policy 5069-A (2024)
- BioMarin RareConnections Coverage Guide
- Texas Department of Insurance IRO Process
- FDA Voxzogo Prescribing Information
- Texas Children's Hospital Skeletal Dysplasia Program
- TDI External Review Request Form (LHL009)
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