By Counterforce Health Team in Crysvita (burosumab) —

How to Renew Crysvita (Burosumab) Coverage with Blue Cross Blue Shield in Pennsylvania: Complete Timeline and Documentation Guide

Answer Box: Renewing Your Crysvita Coverage in Pennsylvania

Blue Cross Blue Shield plans in Pennsylvania typically require annual reauthorization for Crysvita (burosumab) with documented clinical benefit and safety monitoring. Start your renewal 60-90 days before expiration to avoid gaps. Required documentation includes recent fasting serum phosphorus levels, alkaline phosphatase results, and clinical response notes from your specialist. If denied, Pennsylvania's new Independent External Review Program has overturned about 50% of appealed denials since launching in 2024. First step: contact your prescriber's office to schedule renewal labs and verify your current authorization expiration date.

Table of Contents

  1. When to Start Your Renewal Process
  2. Required Documentation and Lab Updates
  3. The Renewal Submission Process
  4. Timeline Expectations and Decision Windows
  5. If Your Coverage Lapses: Bridge Options
  6. Annual Plan Changes to Monitor
  7. Appeals Process in Pennsylvania
  8. Personal Renewal Tracker Template
  9. FAQ

When to Start Your Renewal Process

Blue Cross Blue Shield plans in Pennsylvania typically approve Crysvita for 6-12 months initially, then require annual renewals. The key is starting early—most denials happen because renewal requests arrive after the authorization has already expired.

Renewal Triggers to Watch For

  • 60-90 days before expiration: Ideal time to begin the process
  • Lab scheduling: Allow 2-4 weeks to get appointments and results
  • Formulary changes: January 1st annually (check if Crysvita moves tiers)
  • Plan changes: If you switch Blue Cross entities or coverage types
Tip: Set a calendar reminder for 90 days before your current authorization expires. This gives you buffer time for any complications.

Signs You Should Start Early

Start your renewal process immediately if you notice:

  • Difficulty scheduling specialist appointments
  • Your prescriber mentions they're updating their PA submission process
  • You've received any communication about formulary changes
  • You're switching between Blue Cross entities (e.g., Independence Blue Cross to Highmark)

Required Documentation and Lab Updates

Pennsylvania Blue Cross plans expect comprehensive documentation showing both ongoing medical necessity and treatment safety. Here's what your specialist needs to provide:

Essential Lab Work

Your renewal packet must include recent results for:

  • Fasting serum phosphorus (primary marker—should be within normal range)
  • Total alkaline phosphatase (trending down shows treatment benefit)
  • Serum calcium and creatinine (safety monitoring)
  • Parathyroid hormone (PTH) and 25-hydroxyvitamin D levels
Note: Labs should be drawn within 3 months of your renewal submission. Some plans accept results up to 6 months old, but fresher data strengthens your case.

Clinical Response Documentation

Your specialist's renewal letter should address:

  1. Confirmed diagnosis with genetic testing results or characteristic clinical findings
  2. Current dosing and injection schedule
  3. Objective improvements since starting Crysvita:
    • Normalized or improved serum phosphorus levels
    • Decreased alkaline phosphatase
    • Reduced bone pain or improved mobility
    • Fewer fractures or pseudofractures
    • Growth improvement (in pediatric patients)
  4. Safety monitoring showing no concerning side effects
  5. Continued medical necessity for ongoing treatment

Clinician Corner: Medical Necessity Letter Checklist

For prescribers preparing renewal documentation:

  • Patient demographics and insurance information
  • ICD-10 codes (E83.31 for XLH, M83.8 for TIO)
  • Current Crysvita dose and frequency
  • Baseline vs. current lab values comparison
  • Functional status improvements
  • Imaging results if applicable (bone X-rays, renal ultrasound)
  • Documentation that oral phosphate/active vitamin D remains discontinued
  • Reference to FDA labeling and relevant clinical guidelines

The Renewal Submission Process

Identifying Your Specific Blue Cross Plan

Pennsylvania has multiple Blue Cross entities with different processes:

  • Independence Blue Cross (IBX): Southeastern PA
  • Capital Blue Cross: Central PA
  • Highmark: Western PA and statewide options

Each may use different forms and submission methods. Check your member ID card to confirm your specific plan.

Submission Methods

Most Pennsylvania Blue Cross plans accept renewals via:

  1. Provider portal (preferred method for faster processing)
  2. Fax submission to utilization management
  3. Mail to prior authorization department
  4. Phone for urgent renewals
Important: Verify current submission methods with your specific plan, as these can change annually.

Required Forms

While forms vary by plan, most renewals require:

  • Prior authorization renewal form
  • Updated clinical notes from specialist
  • Recent lab results
  • Any supporting imaging or specialist consultations

Timeline Expectations and Decision Windows

Standard Processing Times

  • Initial review: 5-15 business days
  • Additional information requests: Add 7-10 days
  • Peer-to-peer review (if requested): 3-5 additional days
  • Final determination: Total of 2-4 weeks from complete submission

Expedited Reviews

If you're at risk of missing doses, request an expedited review:

  • Urgent medical need: 72 hours
  • Standard expedited: 3-5 business days

Document why the delay would cause clinical harm (e.g., risk of bone pain recurrence, fracture risk).

If Your Coverage Lapses: Bridge Options

If your renewal is delayed or denied, several options may help maintain continuity:

Manufacturer Support Programs

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters and crafting evidence-backed rebuttals. Their platform helps patients and clinicians navigate complex prior authorization requirements and appeals processes more effectively.

Kyowa Kirin Cares offers several bridge programs:

  • Copay assistance for commercially insured patients
  • Patient Assistance Program for eligible uninsured patients
  • Bridge therapy during coverage gaps (eligibility criteria apply)

Contact Kyowa Kirin Cares directly to discuss temporary supply options while your renewal is processed.

Plan-Level Continuity Options

Some Blue Cross plans offer:

  • Continuity of care provisions for established patients
  • Temporary supply during appeals (typically 30 days)
  • Emergency override for urgent medical situations

Ask your prescriber's office to specifically request these provisions when submitting your renewal or appeal.

Annual Plan Changes to Monitor

January 1st Formulary Updates

Each year, Blue Cross plans may:

  • Change tier placement (affecting copays)
  • Modify prior authorization criteria
  • Update quantity limits
  • Change preferred specialty pharmacies

What to Re-verify Annually

  • Crysvita's formulary status and tier
  • Your specialist's continued network participation
  • Preferred specialty pharmacy options
  • Copay amounts and out-of-pocket maximums
  • Prior authorization form updates

Appeals Process in Pennsylvania

Pennsylvania launched its Independent External Review Program in January 2024, giving patients a powerful new tool for appealing denials.

Internal Appeals (First Step)

  1. File within 180 days of denial
  2. Submit through member portal, fax, or mail
  3. Include denial letter, medical records, specialist letter
  4. Timeline: 30 days for standard, 72 hours for urgent

External Review (After Internal Denial)

Pennsylvania's new program has shown impressive results:

  • Success rate: About 50% of appeals overturned
  • Timeline: 45 days standard, 72 hours expedited
  • Cost: Free to patients
  • Deadline: 4 months after final internal denial

To request external review:

  • Visit pa.gov
  • Submit online or mail forms to Pennsylvania Insurance Department
  • Include all documentation from internal appeals
From our advocates: We've seen several Pennsylvania patients successfully overturn Crysvita denials through the state's external review program by emphasizing the drug's FDA approval for their specific condition and documenting clear clinical benefit with lab improvements. The key was submitting comprehensive medical records showing failed conventional therapy and objective response to treatment.

Personal Renewal Tracker Template

Key Dates to Track

Item Date Status Notes
Current authorization expires _____
Labs scheduled _____
Specialist appointment _____
Renewal submitted _____
Decision expected _____
Next dose due _____

Contact Information to Keep Handy

  • Blue Cross member services number
  • Prescriber's office PA coordinator
  • Specialty pharmacy contact
  • Kyowa Kirin Cares case manager
  • Pennsylvania Insurance Department: (verify current contact on pa.gov)

FAQ

How long does Blue Cross Blue Shield PA renewal take in Pennsylvania? Standard renewals typically take 2-4 weeks. Expedited reviews for urgent medical need are processed within 72 hours.

What if my Crysvita moves to a higher formulary tier? You can request a formulary exception by demonstrating medical necessity and lack of appropriate alternatives. Your prescriber should emphasize Crysvita's unique mechanism of action for XLH and TIO.

Can I request an expedited renewal if I'm running low on medication? Yes, if missing doses would cause clinical harm. Document the medical urgency and potential for bone pain recurrence or fracture risk.

Does step therapy apply to Crysvita renewals? Most Blue Cross policies recognize that patients established on Crysvita have already tried and failed conventional phosphate/calcitriol therapy. Document this history clearly in renewal requests.

What happens if I switch between Pennsylvania Blue Cross plans? You'll need a new prior authorization with the new plan. Start this process immediately upon enrollment to avoid coverage gaps.

How often do I need lab monitoring for renewals? Most plans expect serum phosphorus every 3-6 months once stable, with comprehensive safety labs (calcium, creatinine, PTH) at least annually.

What if my specialist is out-of-network with my new Blue Cross plan? Request a single case agreement for continuity of care, or ask for a referral to an in-network endocrinologist or nephrologist experienced with rare bone diseases.

Can I appeal to Pennsylvania's external review program for coverage gaps? Yes, if you've exhausted internal appeals. The state program has overturned about 50% of denials since launching in 2024.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by specific Blue Cross Blue Shield plan and individual circumstances. Always consult with your healthcare provider and insurance plan directly for personalized guidance. For additional support with complex appeals, consider consulting with Counterforce Health, which specializes in helping patients navigate insurance coverage challenges for specialty medications.

Pennsylvania residents can access free assistance through the Pennsylvania Health Law Project and other consumer advocacy organizations. Contact the Pennsylvania Insurance Department for official guidance on appeals and external review processes.

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