By Counterforce Health Team in Voxzogo (vosoritide) —

How to Get Voxzogo (vosoritide) Covered by Humana Medicare in New York: Complete PA Guide and Appeal Process

Answer Box: Getting Voxzogo Covered by Humana Medicare in New York

Humana Medicare requires prior authorization (PA) for Voxzogo (vosoritide) for pediatric achondroplasia patients ≥2 years old with confirmed FGFR3 genetic variant, open growth plates, and prescription from a pediatric endocrinologist or geneticist. New York residents with Humana Medicare must use the federal Medicare appeals process (not New York State external appeals) if denied. First step today: Call Humana Member Services at 1-800-833-6917 to request PA forms and verify specialty pharmacy requirements. Submit complete documentation including genetic testing, bone age X-rays, and growth velocity data for fastest approval.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Plan Type
  3. Gather What You Need
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timelines
  6. If You're Asked for More Information
  7. If Denied: Medicare Appeals Process
  8. Renewal and Re-Authorization
  9. Costs and Financial Assistance
  10. FAQ

What This Guide Covers

This comprehensive guide helps New York families and clinicians navigate Humana Medicare coverage for Voxzogo (vosoritide), the only FDA-approved treatment for achondroplasia in children. Whether you're dealing with an initial prior authorization, appealing a denial, or preparing for renewal, we'll walk you through each step with specific forms, timelines, and contact information.

Important note for New York residents: Unlike commercial insurance plans, Humana Medicare appeals follow federal Medicare rules, not New York State Department of Financial Services external appeals. This guide focuses on the correct Medicare appeals pathway.

Before You Start: Verify Your Plan Type

Coverage at a Glance

Requirement Details Where to Find It
Plan Type Humana Medicare Advantage (Part C) or Part D Member ID card or Humana member portal
Prior Authorization Required for all Voxzogo prescriptions Call 1-800-833-6917 to confirm
Formulary Status Specialty tier (verify by ZIP code) Humana drug list tool
Specialty Pharmacy Network pharmacy required CenterWell Specialty or approved network
Prescriber Pediatric endocrinologist, geneticist, or specialist Must be REMS-certified

Key Distinction: Part B vs. Part D

Voxzogo is a daily subcutaneous injection administered at home, making it a Part D prescription drug benefit (not Part B medical benefit). This means:

  • 2025 costs: Up to $615 deductible, then tiered copays until you reach the $2,100 out-of-pocket maximum
  • After $2,100: 100% coverage for the rest of the year
  • Specialty pharmacy: Required for home delivery and administration training
Note: Medicare beneficiaries cannot use manufacturer copay assistance programs, but may qualify for other financial support options.

Gather What You Need

Essential Documentation Checklist

Clinical Requirements:

  • Genetic testing report confirming pathogenic FGFR3 variant
  • Recent bone age X-ray (≤12 months) showing open epiphyses
  • Growth velocity data (12+ months preferred for baseline)
  • Clinical notes confirming achondroplasia diagnosis (ICD-10: Q77.4)
  • Current height, weight, and body surface area calculations

Prescriber Requirements:

  • Prescription from pediatric endocrinologist, clinical geneticist, or achondroplasia specialist
  • Provider NPI number and specialty credentials
  • Dosing calculation (0.24 mg/kg subcutaneous daily)
  • Treatment plan and monitoring schedule

Insurance Documentation:

  • Humana member ID card
  • Current formulary status verification
  • Any prior denial letters or EOBs

Common Denial Triggers to Avoid

Denial Reason Required Documentation How to Fix
Missing FGFR3 confirmation Genetic test results or clinical diagnosis Submit lab report with pathogenic variant
Closed growth plates Bone age X-ray showing open epiphyses Provide recent imaging (≤12 months)
Non-specialist prescriber Pediatric endocrinologist/geneticist Transfer prescription to qualified specialist
Age restrictions Patient <18 years old Verify birth date and eligibility
Insufficient growth data Baseline growth velocity measurements Include 12+ months of growth charts

Submit Your Prior Authorization Request

Step-by-Step Submission Process

1. Contact Humana (Same Day)

  • Call Member Services: 1-800-833-6917
  • Request Voxzogo prior authorization forms
  • Confirm specialty pharmacy network requirements
  • Get submission fax number and portal access

2. Complete Documentation (1-3 Days)

  • Download PA forms from Humana provider portal
  • Gather all clinical documentation from checklist above
  • Have prescriber complete medical necessity letter

3. Submit Complete Packet

  • Electronic submission: Via Humana provider portal (fastest)
  • Fax submission: Use number provided by Member Services
  • Include confirmation number: Track all submissions
Tip: Submit electronically when possible. Complete electronic submissions often receive decisions within 1 business day, while complex cases may take up to 30 days.

Medical Necessity Letter Checklist

Your prescriber's letter should include:

  • Patient's confirmed achondroplasia diagnosis with FGFR3 variant details
  • Clinical rationale based on FDA labeling and growth velocity goals
  • Baseline growth measurements and treatment expectations
  • Contraindications to alternative treatments (none FDA-approved)
  • Monitoring plan and safety considerations
  • Reference to FDA prescribing information

Follow-Up and Timelines

Standard Processing Times

  • Standard decisions: Up to 30 days for complex cases
  • Complete submissions: Often 1-3 business days
  • Expedited requests: 72 hours (24 hours for urgent drug needs)
  • Appeals: 60 days for redetermination level

When and How to Follow Up

Week 1: If no response, call Member Services to confirm receipt and processing status.

Sample follow-up script: "I'm calling to check on the status of a Voxzogo prior authorization submitted on [date] for [patient name]. The confirmation number is [number]. Can you tell me the current status and expected decision date?"

Document everything: Keep records of all phone calls, reference numbers, and representative names.

If You're Asked for More Information

Humana may request additional clinical information to support medical necessity. Common requests include:

  • Updated growth measurements: Provide most recent height/weight data
  • Additional imaging: May request updated bone age if previous X-ray is >6 months old
  • Peer-to-peer review: Prescriber discusses case directly with Humana medical director
  • Literature support: Clinical studies supporting Voxzogo efficacy in achondroplasia
From our advocates: "We've seen cases where providing comprehensive growth velocity charts from the past 18 months, rather than just 12 months, helped demonstrate the medical necessity more clearly. The more complete the growth picture, the stronger the case for approval."

If Denied: Medicare Appeals Process

Critical for New York residents: You must use the federal Medicare appeals process, not New York State external appeals. New York's Department of Financial Services external appeals do not apply to Medicare plans.

Medicare Appeals Timeline

Level Deadline to File Decision Timeline Where to Submit
Redetermination 120 days from denial 60 days Humana (plan contractor)
Reconsideration 60 days from redetermination 30 days Qualified Independent Contractor
Administrative Law Judge 60 days (if ≥$190 in controversy) 90 days Office of Medicare Hearings and Appeals

Filing Your Appeal

Step 1: Internal Appeal (Redetermination)

  • Use form provided in denial notice
  • Include all original documentation plus additional evidence
  • Submit via Humana member portal or mail to address in denial letter
  • Call 1-800-MEDICARE (1-800-633-4227) for assistance

Step 2: Independent Review

  • If redetermination is denied, request reconsideration
  • Independent contractor reviews your case
  • Include medical literature supporting Voxzogo use in achondroplasia

BioMarin RareConnections Support

BioMarin RareConnections offers dedicated appeal support:

  • Phone: 1-866-906-6100 (Mon-Fri, 8AM-8PM ET)
  • Email: [email protected]
  • Services: Case management, appeal letter templates, documentation guidance

The program reports >96% success rate in achieving commercial coverage, though Medicare cases may have different outcomes due to federal regulations.

Renewal and Re-Authorization

Annual Renewal Requirements

Humana typically requires annual re-authorization for Voxzogo. Plan ahead by submitting renewal requests 30-60 days before expiration.

Renewal documentation needed:

  • Updated growth velocity data showing treatment response
  • Recent bone age X-ray confirming open epiphyses
  • Continued medical necessity from prescribing specialist
  • Any changes in clinical status or dosing

Measuring Treatment Success

Document positive response with:

  • Improved annualized growth velocity compared to baseline
  • Maintained or improved growth percentiles
  • No significant adverse effects requiring discontinuation
  • Continued open epiphyses on imaging

Costs and Financial Assistance

2025 Medicare Part D Costs

  • Deductible: Up to $615 (varies by plan)
  • Specialty tier: Typically 25-33% coinsurance
  • Out-of-pocket maximum: $2,100 annually
  • After maximum: 100% coverage

Financial Support Options

Since Medicare beneficiaries cannot use manufacturer copay cards, consider:

  • Medicare Extra Help (Low Income Subsidy): Reduces or eliminates Part D costs
  • State pharmaceutical assistance programs: Contact New York State Office for the Aging
  • Charitable foundations: Patient advocate groups for rare disease support

Counterforce Health specializes in turning insurance denials into successful appeals by crafting evidence-backed rebuttals tailored to each payer's specific requirements. Their platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization processes and appeals for specialty medications like Voxzogo.

FAQ

Q: How long does Humana Medicare prior authorization take for Voxzogo in New York? A: Standard decisions take up to 30 days, but complete electronic submissions often receive approval within 1-3 business days. Expedited requests are processed within 72 hours.

Q: What if Voxzogo is not on my Humana formulary? A: Request a formulary exception by demonstrating medical necessity. Your prescriber must show that formulary alternatives are ineffective or contraindicated (though no alternatives exist for achondroplasia).

Q: Can I request an expedited appeal if Voxzogo is denied? A: Yes, if your health is at serious risk due to treatment delay. Contact Humana immediately to request expedited processing (72-hour timeline).

Q: Does New York's external appeal process apply to my Humana Medicare plan? A: No. New York State external appeals only apply to state-regulated plans. Medicare beneficiaries must use the federal Medicare appeals process.

Q: What happens if my child turns 18 during treatment? A: Voxzogo is approved for patients with open epiphyses regardless of age, but verify continued coverage with Humana as they may have age-related policy restrictions.

Q: Can I use a local pharmacy for Voxzogo? A: No, Voxzogo requires specialty pharmacy dispensing through Humana's network (typically CenterWell Specialty Pharmacy) for proper storage, handling, and patient education.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice and should not replace consultation with your healthcare provider or insurance company. Coverage policies and procedures may change. Always verify current requirements with Humana and consult official Medicare resources for the most up-to-date information. For additional help with complex insurance appeals, consider working with experienced advocates like those at Counterforce Health who specialize in turning denials into approvals through targeted, evidence-based appeals.

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