How to Get Voxzogo (Vosoritide) Covered by Humana in Michigan: Prior Authorization, Appeals, and Cost Assistance
Quick Answer: Getting Voxzogo Covered by Humana in Michigan
Voxzogo (vosoritide) requires prior authorization from Humana and is typically covered on the specialty tier. To get approved: 1) Have your pediatric specialist submit a PA request with genetic testing confirming achondroplasia, proof of open growth plates, and medical necessity documentation. 2) If denied, file an internal appeal within 60 days, then request external review through Michigan DIFS within 127 days. 3) Use BioMarin RareConnections for copay assistance (commercial insurance only) and specialty pharmacy coordination. Start by calling Humana at the number on your member ID card to confirm coverage requirements.
Table of Contents
- Coverage Requirements at a Glance
- Step-by-Step: Fastest Path to Approval
- Understanding Your Benefit Design
- Prior Authorization Documentation
- Cost Assistance Options
- Appeals Process in Michigan
- Specialty Pharmacy Requirements
- Common Scripts and Conversation Starters
- FAQ
Coverage Requirements at a Glance
Requirement | What It Means | Where to Find It | Source |
---|---|---|---|
Prior Authorization | Must get approval before filling | Humana formulary, member portal | Humana Drug Lists |
Specialty Tier | Higher copay/coinsurance | Plan documents, EOB | Humana Specialty Rx |
Specialty Pharmacy Only | Cannot use retail pharmacy | CenterWell or approved network | CenterWell Specialty |
Age Requirement | ≥2 years with open growth plates | FDA label, prescriber documentation | FDA Voxzogo Label |
Genetic Testing | Confirmed FGFR3 achondroplasia | Lab report required | Medical necessity criteria |
Step-by-Step: Fastest Path to Approval
1. Confirm Your Coverage (Patient/Family)
Timeline: 1-2 business days
Action: Call Humana member services (number on your ID card) to verify Voxzogo is on your formulary and confirm PA requirements.
Document: Write down your reference number, tier placement, and any specific forms needed.
2. Gather Required Documentation (Clinic)
Timeline: 1-2 weeks
Action: Your pediatric endocrinologist or geneticist collects:
- Genetic test confirming pathogenic FGFR3 variant
- Growth plate X-rays showing open epiphyses
- Growth velocity data and height measurements
- Prior treatment history (if any)
- Current weight for dosing calculations
3. Submit Prior Authorization (Prescriber)
Timeline: Submit within 1 week of documentation gathering
Action: Provider submits PA through Humana provider portal or fax.
Expected Response: 72 hours standard, 24 hours if expedited
4. Coordinate Specialty Pharmacy (If Approved)
Timeline: 2-3 business days
Action: Prescription sent to CenterWell or approved specialty pharmacy for dispensing and patient education.
5. Apply for Cost Assistance (If Commercial Insurance)
Timeline: Concurrent with PA process
Action: Contact BioMarin RareConnections at 1-833-869-9646 for copay assistance enrollment.
Understanding Your Benefit Design
What Drives Your Out-of-Pocket Costs
Voxzogo's placement on Humana's specialty tier typically means you'll pay a percentage of the drug cost (coinsurance) rather than a flat copay. For most Humana Medicare Advantage plans, specialty tier coinsurance ranges from 25-33% after you meet your deductible.
Key Cost Factors:
- Formulary tier placement (specialty = highest cost-sharing)
- Deductible status (must meet medical/pharmacy deductible first)
- Annual out-of-pocket maximum (costs stop once you reach this limit)
- Weight-based dosing (heavier patients need more medication)
Tip: Request your plan's Summary of Benefits to understand exact cost-sharing percentages for specialty drugs.
Benefit Investigation Checklist
When calling Humana, ask for and record:
- Exact specialty tier coinsurance percentage
- Whether pharmacy or medical deductible applies
- Annual out-of-pocket maximum for pharmacy benefits
- Coverage gap/donut hole implications (Medicare Part D)
- Whether quantity limits apply beyond standard 30-day supply
Prior Authorization Documentation
Medical Necessity Letter Requirements
Your prescriber's PA request must include these elements to meet Humana's criteria:
Clinical Documentation:
- Confirmed diagnosis of achondroplasia with ICD-10 code Q77.4
- Genetic testing results showing pathogenic FGFR3 variant
- Patient age (≥2 years) and weight for dosing
- X-ray evidence of open growth plates
- Growth velocity measurements and height percentiles
Treatment Rationale:
- Why Voxzogo is medically necessary for this patient
- Expected treatment goals (improved growth velocity)
- Contraindications to alternative approaches
- Plan for ongoing monitoring and dose adjustments
Clinician Corner: Include citations from the FDA label and relevant clinical studies. Reference the pivotal phase 3 trial data showing improved annualized growth velocity in children with achondroplasia.
Common Denial Reasons & Fixes
Denial Reason | How to Overturn |
---|---|
Missing genetic testing | Submit lab report confirming pathogenic FGFR3 variant |
Age outside criteria | Provide birth certificate showing age ≥2 years |
Growth plates closed | Submit recent X-rays demonstrating open epiphyses |
Non-specialist prescriber | Transfer prescription to pediatric endocrinologist or geneticist |
Insufficient growth data | Include 6-12 months of height/weight measurements |
Cost Assistance Options
BioMarin RareConnections Program
Eligibility: Commercial insurance only (not Medicare, Medicaid, or other government plans)
Benefits: Copay assistance, case management, specialty pharmacy coordination
Contact: 1-833-869-9646, Monday-Friday 8 AM-8 PM PT
Application: Online enrollment
Important: If you have Humana Medicare Advantage, you're not eligible for the manufacturer copay card due to federal anti-kickback regulations.
Alternative Financial Assistance
For Medicare patients or those who don't qualify for manufacturer assistance:
- Contact BioMarin RareConnections for information about foundation grants
- Check with national rare disease organizations for emergency assistance funds
- Explore state pharmaceutical assistance programs (Michigan has limited options for rare diseases)
When dealing with complex insurance coverage challenges, Counterforce Health specializes in turning denials into targeted appeals for specialty medications like Voxzogo. Their platform helps identify the specific denial basis and creates evidence-backed rebuttals aligned to your plan's requirements.
Appeals Process in Michigan
Internal Appeals with Humana
Timeline: Must file within 60 days of denial
Process:
- Call Humana member services to initiate appeal
- Submit written appeal with additional documentation
- Request peer-to-peer review if available
- Receive decision within 30 days (expedited: 72 hours)
External Review Through Michigan DIFS
If Humana upholds the denial, Michigan residents have strong appeal rights:
Timeline: 127 days after final internal denial
Process:
- File External Review Request with Michigan DIFS
- Submit medical records and prescriber letter
- DIFS assigns case to Independent Review Organization (IRO)
- Receive binding decision within 60 days (expedited: 72 hours)
Contact: Michigan DIFS at 877-999-6442 for assistance with the process.
Michigan Advantage: DIFS has previously overturned insurer denials for Voxzogo when medical necessity was demonstrated, as shown in documented cases.
When to Request Expedited Review
Request expedited processing if:
- Delay would seriously jeopardize the child's health
- Current treatment is failing and time-sensitive
- Child is experiencing significant growth delay
Your prescriber must provide a letter stating that delays would be harmful.
Specialty Pharmacy Requirements
CenterWell Specialty Pharmacy
Humana typically requires Voxzogo be dispensed through CenterWell Specialty Pharmacy or an approved network specialty pharmacy.
Key Requirements:
- Prescription must be sent directly from prescriber to specialty pharmacy
- Patient/caregiver education on injection technique required
- Regular refill coordination as child's weight changes
- Temperature-controlled shipping to maintain drug stability
Coordination Tips
- Confirm shipping address and preferred delivery times
- Ensure someone will be available to receive temperature-sensitive medication
- Coordinate refills 7-10 days before running out
- Update pharmacy when child's weight changes significantly (affects dosing)
Common Scripts and Conversation Starters
Calling Humana Member Services
"Hi, I'm calling about prior authorization requirements for Voxzogo, also called vosoritide, for my child with achondroplasia. Can you tell me what documentation is needed and confirm this medication is covered on our plan's formulary?"
Follow-up questions:
- "What's the exact specialty tier coinsurance percentage?"
- "Does our pharmacy deductible need to be met first?"
- "Can you provide the prior authorization form number or direct me to the online portal?"
Prescriber Peer-to-Peer Request
"I'd like to request a peer-to-peer review for my patient's Voxzogo prior authorization. The child has genetically confirmed achondroplasia with open growth plates, and this is the only FDA-approved treatment for their condition. When can we schedule the clinical review?"
Pharmacy Coordination Call
"I'm calling to set up Voxzogo for my child. We have Humana insurance and the prior authorization was just approved. Can you walk me through the patient education requirements and shipping process?"
FAQ
How long does Humana prior authorization take for Voxzogo?
Standard timeline is 72 hours from when Humana receives the complete PA request. Expedited requests are processed within 24 hours if medical urgency is documented.
What if Voxzogo isn't on Humana's formulary?
You can request a formulary exception through the coverage determination process. Your prescriber must submit a statement explaining medical necessity within 72 hours.
Can I use a retail pharmacy for Voxzogo?
No, Humana requires specialty drugs like Voxzogo to be dispensed through approved specialty pharmacies due to handling requirements and patient education needs.
Does step therapy apply to Voxzogo?
Generally no, since Voxzogo is the only FDA-approved medication for achondroplasia. However, some plans may require documentation that supportive care has been tried.
What happens if my child's weight changes significantly?
Contact both your prescriber and the specialty pharmacy. Voxzogo dosing is weight-based (0.24 mg/kg daily), so dose adjustments and new prior authorizations may be needed.
Can I appeal if Humana says the medication isn't medically necessary?
Yes, you can file an internal appeal and then request external review through Michigan DIFS. Include growth data, genetic testing, and a detailed letter from your pediatric specialist explaining why Voxzogo is necessary for your child's care.
From our advocates: We've seen families succeed with Voxzogo appeals by organizing all documentation before the initial PA request—genetic testing, growth charts, and X-rays showing open growth plates. Having everything ready upfront prevents delays and shows the medical team's thoroughness. Remember that persistence often pays off, especially with Michigan's strong external review process.
Getting Voxzogo covered requires patience and thorough documentation, but Michigan families have good success rates when they follow the proper channels and gather complete medical evidence. Counterforce Health can help streamline this process by creating targeted appeals that address your specific plan's requirements and denial reasons.
Sources & Further Reading
- Humana Drug Lists and Prior Authorization
- Michigan DIFS External Review Process
- BioMarin RareConnections Voxzogo Support
- FDA Voxzogo Prescribing Information
- Humana Member Exceptions and Appeals
- CenterWell Specialty Pharmacy
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal procedures may change. Always verify current requirements with your insurance plan and consult your healthcare provider for medical decisions. For assistance with Michigan insurance regulations, contact the Department of Insurance and Financial Services at 877-999-6442.
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