By Counterforce Health Team in Voxzogo (vosoritide) —

How to Get Voxzogo (vosoritide) Covered by Blue Cross Blue Shield in Ohio: Complete 2025 Prior Authorization Guide

Answer Box: Getting Voxzogo Covered in Ohio

Blue Cross Blue Shield Ohio requires prior authorization for Voxzogo (vosoritide) with genetic confirmation of FGFR3 variant and proof of open growth plates. Submit through the NovoLogix or Availity provider portal with complete documentation. Standard approval takes 15 business days; expedited reviews complete within 72 hours for urgent cases. If denied, you have 180 days to file an internal appeal, followed by external review through Ohio's Department of Insurance. First step today: Contact BioMarin RareConnections at 1-833-869-9646 for payer-specific documentation checklist and benefits verification.

Table of Contents

What This Guide Covers

This guide helps Ohio families and their healthcare providers navigate Blue Cross Blue Shield's prior authorization process for Voxzogo (vosoritide), the first FDA-approved treatment for achondroplasia in children. Whether you're dealing with Anthem Blue Cross Blue Shield in Ohio or another Blue plan, we'll walk you through the exact steps, required documentation, and appeal options specific to Ohio's regulations.

Voxzogo is a daily subcutaneous injection that increases growth velocity in children with achondroplasia who have open growth plates. At approximately $320,000 annually before rebates, securing insurance coverage is crucial for most families.

Who this helps: Parents of children diagnosed with achondroplasia, pediatric endocrinologists and geneticists prescribing Voxzogo, and specialty pharmacy coordinators managing prior authorizations.

Before You Start: Verify Your Coverage

Check Your Plan Type

Not all Blue Cross Blue Shield plans in Ohio operate under the same rules. Contact the member services number on your insurance card to verify:

  • Plan type: Commercial HMO/PPO, Medicare Advantage, or Medicaid managed care
  • Formulary status: Whether Voxzogo is covered and at what tier
  • Network requirements: Which specialty pharmacies are in-network
  • Prior authorization status: Current PA policy number (typically ING-CC-0213 for Anthem Ohio)
Tip: Self-funded employer plans (ERISA) may have different appeal rights than state-regulated plans. Ask specifically which type of plan you have.

Confirm Specialist Network Status

Blue Cross Blue Shield Ohio typically requires Voxzogo to be prescribed by a pediatric endocrinologist or geneticist who's in-network. Verify your prescriber's network status through the Anthem provider directory or by calling provider services at 800-901-0020.

Gather What You Need

Essential Documentation Checklist

Based on Blue Cross Blue Shield's medical necessity criteria and BioMarin RareConnections requirements, you'll need:

Document Details Where to Get It
Genetic test results FGFR3 pathogenic variant confirmation (typically p.Gly380Arg) Genetics lab report
Bone age X-ray Within 12 months showing open epiphyses Radiology department
Growth data 12+ months of height/weight with velocity calculations Pediatric records
Specialist evaluation Medical necessity letter from endocrinologist/geneticist Prescribing physician
Insurance information Member ID, group number, card copies Insurance card
BioMarin forms Patient Enrollment Form (PEF) and Patient Caregiver Form (PCF) RareConnections program

Medical Necessity Letter Requirements

Your prescriber's letter should include:

  • Confirmed achondroplasia diagnosis with genetic testing date
  • Patient's current age, height Z-score, and growth velocity
  • Documentation of open growth plates
  • Treatment goals and expected outcomes
  • Absence of contraindications (severe obesity, hypotension)

Counterforce Health helps clinicians craft evidence-backed medical necessity letters that align with each payer's specific criteria, reducing the back-and-forth that often delays approvals. Their platform automatically identifies the key clinical facts Blue Cross Blue Shield requires and weaves in the appropriate FDA labeling and clinical study citations.

Submit the Prior Authorization Request

Preferred Submission Methods

Blue Cross Blue Shield Ohio (Anthem) accepts PA requests through multiple channels:

NovoLogix Portal (Recommended for specialty drugs):

  • Real-time status tracking
  • Upload all supporting documents
  • Standard processing: 15 business days
  • Expedited: 72 hours for urgent cases

Availity Provider Portal:

  • Check "Specialty Pharmacy Prior Authorization Master Opt-in/out Group List" for plan participation
  • Same timelines as NovoLogix

Fax/Phone Backup:

  • Use forms from anthem.com
  • Call member services number on ID card for plan-specific requirements

Clean Request Packet Tips

To avoid delays and requests for additional information:

  1. Complete all form fields - blank sections trigger automatic requests for more information
  2. Include diagnosis codes - Primary: Q77.4 (Achondroplasia); relevant procedure codes
  3. Attach all supporting docs at initial submission rather than waiting to be asked
  4. Use clear file names when uploading (e.g., "Smith_John_GeneticTest_2024.pdf")

Follow-Up and Timeline Management

Standard Processing Times

Review Type Timeline When to Follow Up
Standard PA 15 business days Day 10 if no update
Expedited PA 72 hours 24 hours if urgent
Additional info requested 5-7 business days after submission Day 3 if critical

Sample Follow-Up Script

When calling Blue Cross Blue Shield Ohio member services:

"Hi, I'm calling to check the status of a prior authorization request for Voxzogo submitted on [date]. The member ID is [number] and the reference number is [if available]. Can you tell me if any additional information is needed and the expected decision timeline?"

Document everything: Reference numbers, representative names, and next steps.

If You're Asked for More Information

Blue Cross Blue Shield may request additional clinical documentation to establish medical necessity. Common requests include:

Medical Necessity Questions

  • "Provide evidence of confirmed achondroplasia" → Submit genetic testing report showing FGFR3 variant
  • "Document growth failure" → Include growth charts showing velocity below normal range
  • "Confirm open growth plates" → Attach recent bone age X-ray with radiologist interpretation

Literature and Guidelines

If asked for supporting evidence, reference:

  • FDA label for Voxzogo
  • Clinical trial data showing +1.57 cm/year growth velocity improvement
  • American College of Medical Genetics guidelines for achondroplasia management

Respond to requests within the specified timeframe (typically 10-14 days) to avoid automatic denials.

If Your Request is Denied

Ohio Appeals Process Timeline

Ohio provides robust appeal rights for Blue Cross Blue Shield denials:

Appeal Level Filing Deadline Decision Timeline How to File
Internal Appeal (1st level) Contact promptly per denial notice ≤30 days Via insurer process
Internal Appeal (2nd level) 60 days from 1st level denial ≤30 days Written request
External Review 180 days from final internal denial ≤30 days Ohio Department of Insurance

Common Denial Reasons and Solutions

"Not medically necessary":

  • Appeal with additional clinical evidence
  • Request peer-to-peer review with medical director
  • Include natural history data showing untreated height deficit

"Experimental/investigational":

  • Cite FDA approval and clinical trial data
  • Reference Blue Cross Blue Shield's own medical policy criteria

"Documentation insufficient":

  • Submit complete genetic testing report
  • Provide detailed growth velocity calculations
  • Include specialist's detailed treatment plan

External Review in Ohio

If internal appeals fail, Ohio residents can request external review through the Ohio Department of Insurance. Call their consumer hotline at 800-686-1526 for assistance.

The external review is conducted by independent medical experts and is binding on the insurer. Ohio's consumer-friendly regulations ensure insurers can't wrongly block reviews.

Renewal and Re-Authorization

When to Resubmit

Blue Cross Blue Shield typically requires annual re-authorization for Voxzogo. Calendar reminders for:

  • 90 days before expiration: Start gathering updated documentation
  • 60 days before: Submit renewal PA request
  • 30 days before: Follow up if no decision received

Renewal Documentation

Include updated:

  • Growth data showing continued response
  • Bone age X-ray confirming open growth plates
  • Specialist evaluation of ongoing medical necessity
  • Any new clinical evidence supporting continued treatment

Quick Reference Checklist

Before Starting:

  • Verify Blue Cross Blue Shield Ohio plan type and network status
  • Confirm Voxzogo formulary coverage
  • Enroll in BioMarin RareConnections (1-833-869-9646)

Documentation Needed:

  • Genetic test confirming FGFR3 variant
  • Bone age X-ray (within 12 months)
  • 12+ months growth data
  • Medical necessity letter from specialist
  • Insurance card copies
  • BioMarin enrollment forms

Submission:

  • Submit via NovoLogix or Availity portal
  • Include all documents at initial submission
  • Document reference numbers and submission dates

If Denied:

  • File internal appeal within timeline
  • Request peer-to-peer review
  • Consider external review through Ohio DOI

FAQ

How long does Blue Cross Blue Shield PA take in Ohio? Standard prior authorizations are processed within 15 business days. Expedited reviews for urgent cases are completed within 72 hours.

What if Voxzogo is non-formulary? You can request a formulary exception by demonstrating medical necessity and lack of appropriate alternatives. Include detailed clinical justification.

Can I request an expedited appeal? Yes, if a physician certifies that delays would jeopardize your child's health or treatment effectiveness. Expedited appeals are decided within 72 hours.

Does step therapy apply to Voxzogo? Typically no, as there are no FDA-approved alternatives for achondroplasia. However, plans may require documentation of failed supportive therapies.

What if my employer plan is self-funded? Self-funded ERISA plans have federal appeal rights rather than Ohio state protections. Check your Summary Plan Description for specific procedures.

How much does Voxzogo cost without insurance? List price is approximately $320,000 annually before rebates. BioMarin RareConnections offers patient assistance programs for eligible families.

Sources and Further Reading

Disclaimer: This guide provides general information about insurance coverage and should not be considered medical or legal advice. Coverage policies vary by plan and change over time. Always verify current requirements with your specific Blue Cross Blue Shield plan and consult with your healthcare provider about treatment decisions.

For complex prior authorization challenges, Counterforce Health specializes in turning insurance denials into successful appeals by crafting targeted, evidence-backed submissions that align with each payer's specific criteria.

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