By Counterforce Health Team in Voxzogo (vosoritide) —

How to Get Voxzogo (Vosoritide) Covered by Humana in Washington: Appeals, Forms, and Provider Collaboration

Answer Box: Getting Voxzogo Covered by Humana in Washington

Voxzogo (vosoritide) requires prior authorization from Humana for pediatric achondroplasia treatment. The fastest path to approval: (1) Have your pediatric endocrinologist or geneticist submit a complete PA request with FGFR3 genetic testing, growth plate imaging, and medical necessity documentation, (2) If denied, file an internal appeal within 65 days, (3) Request external review through Washington's Office of the Insurance Commissioner if needed. Start today by calling BioMarin RareConnections at 1-866-906-6100 for PA support and documentation checklists.

Table of Contents

Set Your Goal: Understanding Humana's Requirements

Getting Voxzogo (vosoritide) approved by Humana requires understanding what the insurer needs to see. Humana requires prior authorization for high-cost specialty medications like Voxzogo, which treats achondroplasia in children.

Your partnership with your provider is essential. Humana's approval hinges on clinical documentation that proves medical necessity. This isn't just about having the right diagnosis—it's about presenting a complete picture that satisfies their coverage criteria.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Approval needed before coverage Humana PA Search Tool
Age Eligibility Child ≥5 months with achondroplasia FDA Voxzogo Label
Genetic Confirmation FGFR3 mutation testing required Clinical genetics lab report
Open Growth Plates X-ray evidence of growth potential Skeletal imaging studies
Specialist Prescriber Pediatric endocrinologist/geneticist Provider credentialing verification

The good news? Humana's Medicare Advantage PA denial rate is only about 3.5%—among the lowest of major insurers. When denials do occur, they're often due to incomplete documentation rather than coverage exclusions.

Visit Preparation: Gathering Your Evidence

Before meeting with your pediatric endocrinologist or geneticist, prepare a comprehensive timeline that supports your case for Voxzogo.

Symptom and Growth Documentation

Create a detailed record of your child's:

  • Growth measurements over time (height, weight, head circumference)
  • Functional challenges related to achondroplasia
  • Previous treatments attempted and their outcomes
  • Family history of skeletal dysplasias

Treatment History Timeline

Document any prior therapies, even if limited options exist for achondroplasia:

  • Growth hormone trials (if attempted)
  • Physical therapy interventions
  • Orthopedic consultations or procedures
  • Sleep study results (common in achondroplasia)
Tip: Bring printed growth charts showing your child's trajectory. Achondroplasia-specific growth charts are available through the AAP health supervision guidelines and help demonstrate the need for intervention.

Building Your Evidence Kit

Your evidence kit should include both diagnostic confirmation and clinical rationale for Voxzogo therapy.

Essential Documentation

Genetic Testing Results

  • FGFR3 gene analysis confirming pathogenic variant (typically c.1138G>A)
  • Laboratory report from certified genetics lab
  • Interpretation by board-certified geneticist

Imaging Studies

  • Recent skeletal X-rays showing open growth plates
  • Previous imaging demonstrating characteristic achondroplasia features
  • Growth plate assessment confirming treatment eligibility

Clinical Notes

  • Specialist evaluation from pediatric endocrinology or genetics
  • Documentation of achondroplasia diagnosis and severity
  • Assessment of growth velocity and treatment goals

Supporting Literature

While your provider will handle clinical references, familiarize yourself with key evidence:

  • FDA approval data showing Voxzogo's efficacy in clinical trials
  • Growth velocity improvements documented in pivotal studies
  • Safety profile in pediatric achondroplasia population

Medical Necessity Letter Structure

Your provider's medical necessity letter is the cornerstone of your PA request. Here's what it should include:

Clinical Rationale Framework

Patient-Specific Information:

  • Confirmed achondroplasia diagnosis with genetic testing
  • Current growth parameters and percentiles
  • Functional impact of short stature
  • Treatment goals and expected outcomes

Medical Necessity Justification:

  • Why Voxzogo is appropriate for this patient
  • Absence of effective alternatives for achondroplasia
  • Timing considerations (growth plates must be open)
  • Monitoring plan and safety considerations
Clinician Corner: The letter should emphasize Voxzogo's unique mechanism as a CNP analog that addresses the underlying FGFR3 pathway dysfunction in achondroplasia. Reference the FDA label and clinical trial data showing sustained growth velocity improvements.

BioMarin RareConnections provides sample medical necessity letter templates and coverage authorization guides specifically for payer submissions.

Provider Support: Peer-to-Peer Strategy

If initial PA is denied, peer-to-peer review can be highly effective. Here's how to support your provider:

Preparation for Peer-to-Peer

Clinical Summary (one page):

  • Patient age, weight, and achondroplasia confirmation
  • Growth velocity data and percentile tracking
  • Rationale for Voxzogo timing
  • Safety monitoring plan

Provider Availability:

  • Offer flexible scheduling for peer-to-peer calls
  • Ensure your specialist can discuss the case directly
  • Prepare key talking points about medical necessity

Key Discussion Points

Your provider should emphasize:

  • Achondroplasia as a genetic condition with limited treatment options
  • Voxzogo's FDA approval and clinical evidence
  • Patient-specific factors supporting treatment
  • Consequences of delayed therapy (growth plate closure)

After Your Visit: Documentation

Maintain organized records of all communications and submissions:

What to Save

  • Copy of PA submission and supporting documents
  • Humana reference numbers and submission dates
  • Provider notes from peer-to-peer discussions
  • All correspondence from Humana

Portal Communication

Use Humana's member portal to:

  • Track PA status and decisions
  • Upload additional documentation if requested
  • Communicate with your care team
  • Schedule follow-up appointments

Appeals Process in Washington

If Humana denies coverage, Washington provides strong consumer protections through multiple appeal levels.

Internal Appeals with Humana

Timeline: 65 days from denial notice to file appeal Decision Time: 7 calendar days for Part D medications How to File: Online portal, phone, fax, or mail

Washington External Review

If internal appeals fail, Washington's external review process provides independent evaluation:

Timeline: 180 days from final internal denial to request external review Decision Time: 30 days for standard review, 72 hours for expedited Process: Submit request to Washington Office of the Insurance Commissioner Cost: No charge to consumer

Note: Washington's external review is binding on the insurer if they overturn the denial. The state maintains certified Independent Review Organizations (IROs) with medical specialists who evaluate cases independently.

When to Request Expedited Review

Request expedited processing if:

  • Delay could seriously jeopardize your child's health
  • Growth plates are approaching closure
  • Current treatment is inadequate

Contact the OIC Consumer Advocacy line at 1-800-562-6900 for guidance on the appeals process.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Missing genetic testing Submit FGFR3 analysis Certified lab report with pathogenic variant
Age outside criteria Verify FDA labeling Birth certificate + current FDA approval (≥5 months)
Closed growth plates Provide recent imaging X-rays confirming open epiphyses
Non-specialist prescriber Transfer care Board-certified pediatric endocrinologist/geneticist
Insufficient medical necessity Enhanced documentation Comprehensive clinical notes + growth data

Cost Support Options

BioMarin RareConnections

Coverage Authorization Resources BioMarin provides downloadable guides including:

  • Payer requirements checklist
  • Sample medical necessity letters
  • Insurance navigation guides

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals through evidence-backed advocacy. Our platform helps patients and providers navigate complex prior authorization requirements for specialty medications like Voxzogo, providing targeted appeals that address specific payer criteria and denial reasons. We work with families across Washington to secure coverage for essential treatments. Learn more at www.counterforcehealth.org.

FAQ

How long does Humana prior authorization take for Voxzogo? Standard PA decisions come within 72 hours of receiving complete documentation. Expedited requests are decided within 24 hours if approved.

What if Voxzogo is not on Humana's formulary? Request a formulary exception with medical necessity documentation. Humana provides 31-day emergency fills during the review process.

Can I appeal if I live in Washington but have an employer plan? Self-funded employer plans may not be subject to Washington state appeals laws. Contact the U.S. Department of Labor for ERISA plan guidance, though many employers voluntarily use external review processes.

Does step therapy apply to Voxzogo? Achondroplasia has no FDA-approved alternatives, making step therapy requirements inappropriate. Emphasize this in your medical necessity documentation.

How much does Voxzogo cost without insurance? List price is approximately $320,000 annually before rebates, making insurance coverage essential. BioMarin RareConnections offers support programs for eligible patients.

What specialists can prescribe Voxzogo in Washington? Pediatric endocrinologists and geneticists at Seattle Children's Hospital and University of Washington are the primary prescribers for achondroplasia treatments in the Pacific Northwest.

Sources & Further Reading

Disclaimer: This information is for educational purposes and should not replace professional medical advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Consult your healthcare provider and insurance plan for specific guidance. For additional support with insurance appeals in Washington, contact Counterforce Health or the Washington Office of the Insurance Commissioner.

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