By Counterforce Health Team in Crysvita (burosumab) —

Lowering Out-of-Pocket for Crysvita (burosumab) with Aetna (CVS Health) in Ohio: Copay Assistance, Tiering & Appeals

Quick Answer: Reducing Crysvita (burosumab) Costs with Aetna (CVS Health) in Ohio

Crysvita costs $4,451-$13,354 per vial depending on dose. With Aetna (CVS Health), expect 50% coinsurance on this specialty-tier medication. Three key cost-reduction strategies: 1) Enroll in Kyowa Kirin Cares copay assistance (commercial insurance only), 2) Request formulary tier exception if denied, 3) Use Aetna Specialty Pharmacy for coordination. Start today: Call Kyowa Kirin Cares at 833-552-2737 to check eligibility and begin enrollment while your provider submits prior authorization.

Table of Contents

Understanding Crysvita Costs with Aetna

Crysvita (burosumab) is a high-cost specialty medication with wholesale acquisition costs ranging from $4,451.45 to $13,354.36 per vial, depending on the concentration needed for weight-based dosing. Under Aetna (CVS Health) plans, this translates to significant out-of-pocket costs due to several benefit design factors.

Formulary Placement and Cost-Sharing

Crysvita is classified as a specialty medication requiring prior authorization and is typically placed on the highest formulary tier. Most Aetna plans in Ohio require 50% coinsurance for specialty drugs, meaning you pay half the negotiated rate after meeting your deductible.

Medical vs. Pharmacy Benefit

Crysvita is covered under the medical benefit rather than the pharmacy benefit, which affects your cost-sharing structure. This means costs count toward your medical deductible and out-of-pocket maximum, not your prescription drug limits.

Note: The total annual cost for Crysvita can exceed $100,000 depending on dosing frequency, making cost management strategies essential for most patients.

Benefit Investigation: What to Ask

Before starting treatment, conduct a thorough benefit investigation to understand your specific coverage and costs. Contact Aetna Member Services and ask these key questions:

Essential Coverage Questions

  • What is my specialty drug coinsurance percentage?
  • What are my annual deductible and out-of-pocket maximum?
  • Does Crysvita require prior authorization or step therapy?
  • Which specialty pharmacies are in-network?
  • Are there quantity limits or frequency restrictions?

Information to Record

  • Reference number from your call
  • Representative's name and date
  • Specific benefit details provided
  • Any coverage limitations mentioned

Counterforce Health specializes in helping patients navigate these complex benefit investigations and can assist with gathering the documentation needed for successful prior authorization submissions.

Manufacturer Copay Assistance

The Kyowa Kirin Cares Co-Pay Assistance Program offers significant financial support for eligible patients with commercial insurance.

Eligibility Requirements

  • U.S. resident with commercial (private) insurance
  • Valid prescription for FDA-approved Crysvita indication
  • Not enrolled in Medicare, Medicaid, TRICARE, VA, or other government programs
  • Enrollment by patient or legal guardian (not insurance companies)

Program Benefits

  • Covers eligible out-of-pocket costs and cost-sharing
  • Includes both medication and administration costs
  • Annual maximum benefit (call for current limits)
  • Support throughout the calendar year

Enrollment Process

  1. Healthcare provider downloads enrollment form
  2. Fax completed form to 833-552-3299
  3. Benefits investigation completed within 2 business days
  4. Case manager contacts provider if prior authorization needed

For questions or enrollment assistance, call 833-KK-CARES (833-552-2737), Monday-Friday, 8 AM-8 PM ET.

Additional Support for Government-Insured Patients

Patients with Medicare, Medicaid, or TRICARE can work with dedicated case managers to explore alternative financial options, including potential Patient Assistance Program eligibility for those experiencing financial hardship.

Formulary Tier Exceptions

If Crysvita's specialty tier placement creates unaffordable costs, you can request a formulary exception to move it to a lower-cost tier.

When to Request an Exception

  • Standard specialty coinsurance exceeds your budget
  • Lower-tier alternatives are contraindicated
  • You've tried and failed formulary-preferred treatments

Required Documentation Your prescriber must submit a detailed medical necessity statement including:

  • Clinical rationale for Crysvita over alternatives
  • Documentation of prior treatment failures or contraindications
  • Evidence from FDA labeling or clinical guidelines supporting use
  • Specific diagnosis codes and treatment history

Exception Process Timeline

Tip: Include specialist consultation notes and any relevant clinical trial data to strengthen your exception request.

Specialty Pharmacy Coordination

Proper specialty pharmacy selection and coordination can reduce costs and improve access to Crysvita.

Network Requirements

All initial Crysvita fills must be dispensed through an Aetna network specialty pharmacy, such as:

  • Aetna Specialty Pharmacy
  • CVS Specialty
  • In Ohio: The Ohio State University Outpatient Pharmacy (Columbus)

Supply and Cost Management

  • Maximum 30-day supply per fill
  • Coordination of delivery options (home, doctor's office)
  • Medication counseling and injection training
  • Adherence support and refill reminders

Coordination Benefits CVS Specialty provides comprehensive support including case management, prior authorization assistance, and coordination with your healthcare team to ensure seamless access.

Contact Aetna Specialty Pharmacy at 1-866-782-2779 for prescription coordination and benefits assistance.

Appeals on Cost Grounds

When formulary exceptions are denied or costs remain prohibitive, you can appeal Aetna's coverage decisions through Ohio's structured process.

Ohio Appeals Process

Internal Appeals (Required First Step)

  • File within 180 days of denial
  • Two levels of internal review available
  • Standard timeframe: 30-45 days per level
  • Expedited reviews: 72 hours for urgent cases

External Review (After Internal Appeals)

  • File within 180 days of final internal denial
  • Request submitted to Aetna, who notifies Ohio Department of Insurance
  • Independent Review Organization (IRO) assigned
  • Decision typically within 30 days (72 hours for expedited)
  • IRO decision is binding on Aetna

Required Documentation for Cost-Based Appeals

  • Denial letters and internal appeal responses
  • Detailed financial hardship documentation
  • Evidence that lower-cost alternatives are inappropriate
  • Clinical support for medical necessity

For assistance with Ohio appeals, contact the Ohio Department of Insurance Consumer Services at 1-800-686-1526.

Annual Renewal Planning

Plan ahead for potential coverage changes that could affect your Crysvita costs.

What Can Change Annually

  • Formulary tier placement
  • Prior authorization requirements
  • Specialty pharmacy network
  • Coinsurance percentages
  • Deductible and out-of-pocket maximums

Renewal Preparation Checklist

  • Review new formulary and benefit documents (typically available in October)
  • Confirm continued network specialty pharmacy participation
  • Renew manufacturer copay assistance enrollment
  • Update financial assistance applications if needed
  • Schedule benefit investigation call before January 1st
Important: Manufacturer copay assistance programs typically reset annually and require re-enrollment.

Conversation Scripts

Script for Aetna Member Services "I'm calling about coverage for Crysvita, also called burosumab, for X-linked hypophosphatemia. I need to understand my specialty drug benefits, including my coinsurance percentage, deductible, and which specialty pharmacies are in-network. Can you also confirm if prior authorization is required and what the approval timeline is?"

Provider Script for Prior Authorization "I'm requesting prior authorization for Crysvita (burosumab) for a patient with confirmed X-linked hypophosphatemia. I have the required genetic testing, baseline phosphorus levels, and clinical documentation ready. What's the fastest way to submit this request, and can we discuss the medical necessity criteria?"

Specialty Pharmacy Coordination Script "I'm starting Crysvita through Aetna and need to coordinate with specialty pharmacy. Can you help me understand the dispensing process, delivery options, and any cost-sharing assistance available? I'd also like to enroll in any adherence support programs."

When navigating complex insurance coverage decisions, Counterforce Health helps patients and providers turn denials into successful appeals with targeted, evidence-backed documentation that meets payer-specific requirements.

FAQ

How much does Crysvita cost with Aetna in Ohio? With typical 50% specialty drug coinsurance, expect to pay $2,200-$6,700 per vial before copay assistance. Annual costs can exceed $50,000 without manufacturer support programs.

Can I get copay assistance if I have Aetna? Yes, if you have commercial Aetna coverage. The Kyowa Kirin Cares program covers eligible out-of-pocket costs. Government insurance (Medicare, Medicaid) patients aren't eligible for copay assistance but may qualify for other support.

What if Crysvita isn't covered by my Aetna plan? Request a formulary exception with detailed medical necessity documentation. If denied, appeal through Ohio's two-level internal process, then external review through an Independent Review Organization.

How long does Aetna prior authorization take in Ohio? Standard prior authorization decisions typically take 30-45 days. Expedited requests (when delay risks serious harm) are decided within 72 hours.

Which specialty pharmacy should I use in Ohio? Aetna requires network specialty pharmacies. Options include Aetna Specialty Pharmacy, CVS Specialty, or The Ohio State University Outpatient Pharmacy in Columbus.

Can I appeal if my copay assistance is denied? Manufacturer copay assistance decisions are separate from insurance coverage. If denied by Kyowa Kirin Cares, work with their case managers to explore alternative financial assistance options.

What happens if I can't afford my Crysvita copay? Explore multiple options: manufacturer patient assistance programs, rare disease foundation grants, hospital financial aid, and state pharmaceutical assistance programs. Case managers can help coordinate these resources.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and costs vary by specific plan. Always verify current information with your insurance provider and healthcare team.

Sources & Further Reading

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