By Counterforce Health Team in Crysvita (burosumab) —

Myths vs. Facts: Getting Crysvita (Burosumab) Covered by Cigna in Pennsylvania

Answer Box: Getting Crysvita Covered by Cigna in Pennsylvania

Eligibility: Cigna requires prior authorization for Crysvita (burosumab) in Pennsylvania with specific criteria: confirmed XLH diagnosis via PHEX gene mutation or elevated FGF23, age 6+ months, specialist prescription, and attestation of no concurrent phosphate/vitamin D use. Fastest path: Submit complete PA through Express Scripts portal with genetic testing, baseline labs, and specialist notes. First step today: Contact your prescriber to gather required documentation and initiate the PA process through Cigna's specialty pharmacy network.

Table of Contents

  1. Why Myths About Crysvita Coverage Persist
  2. Common Myths vs. Facts
  3. What Actually Influences Approval
  4. Avoid These Critical Mistakes
  5. Quick Action Plan: Three Steps to Take Today
  6. Pennsylvania External Review Process
  7. Resources and Support

Why Myths About Crysvita Coverage Persist

Crysvita (burosumab) coverage myths spread because this specialty medication operates differently from typical prescriptions. At roughly $4,451-$13,354 per vial depending on strength, it's managed through Express Scripts/Accredo specialty pharmacy with strict prior authorization requirements that many patients and even some providers don't fully understand.

The complexity increases in Pennsylvania, where patients have access to a new state-run external review program that's overturning about 50% of insurance denials. However, misinformation about coverage criteria and appeals processes can delay access to this life-changing treatment for X-linked hypophosphatemia (XLH).

Common Myths vs. Facts

Myth 1: "If my doctor prescribes Crysvita, Cigna has to cover it"

Fact: Cigna requires specific prior authorization criteria including confirmed XLH diagnosis, specialist involvement, and documentation that you won't use it with oral phosphate or active vitamin D. A prescription alone isn't sufficient.

Myth 2: "I need to try other treatments first before getting Crysvita"

Fact: For pediatric patients under 18, step therapy typically isn't required. However, adults (18+) must show inadequate response, contraindication, or intolerance to oral phosphate and/or calcitriol therapy before approval.

Myth 3: "Genetic testing isn't necessary if I have obvious XLH symptoms"

Fact: Cigna requires either a PHEX gene mutation confirmation OR elevated serum FGF23 levels above age-specific normal ranges. Clinical symptoms alone won't secure approval.

Myth 4: "Any doctor can prescribe Crysvita"

Fact: The prescription must come from or be written in consultation with a physician experienced in metabolic bone disease—typically an endocrinologist, geneticist, nephrologist, or XLH specialist.

Myth 5: "If Cigna denies my request, I'm out of options"

Fact: Pennsylvania's Independent External Review Program has overturned about 50% of appealed denials in its first year. You have multiple appeal levels available.

Myth 6: "I can use Crysvita with my current phosphate supplements"

Fact: Providers must attest that Crysvita will NOT be used concurrently with oral phosphate and/or active vitamin D analogs. You must discontinue these one week before starting Crysvita.

Myth 7: "Medicare Advantage plans have the same requirements as commercial Cigna"

Fact: Some Cigna Medicare Advantage plans may not require prior authorization for certain billing scenarios. Always verify your specific plan requirements.

Myth 8: "The appeals process takes months"

Fact: Pennsylvania's external review process issues decisions within 45 days for standard reviews and 72 hours for expedited reviews when life or health is at serious risk.

What Actually Influences Approval

Core Documentation Requirements

Cigna's approval decisions center on four key areas:

1. Diagnosis Confirmation

  • PHEX gene mutation results, OR
  • Elevated serum FGF23 levels with reference ranges
  • Baseline fasting serum phosphorus concentrations

2. Prescriber Qualifications

  • Specialist credentials (endocrinology, genetics, nephrology, or metabolic bone disease experience)
  • Clinical notes documenting XLH signs/symptoms

3. Age and Dosing Compliance

  • Patient ≥6 months old
  • Pediatric (<18): Maximum 90 mg subcutaneously every 2 weeks
  • Adult (≥18): Maximum 90 mg subcutaneously every 4 weeks

4. Treatment History (Adults Only)

  • Documentation of inadequate response to oral phosphate/calcitriol
  • Contraindications or intolerance to standard therapy
  • Attestation of no concurrent use with prohibited medications
From Our Advocates: We've seen cases where initial denials were overturned simply by providing complete genetic testing results and specialist attestation forms. The key is submitting all required documentation upfront rather than piecemeal responses to requests for additional information.

Avoid These Critical Mistakes

1. Incomplete Genetic Documentation

Don't submit requests without either PHEX mutation results or FGF23 levels with reference ranges. Cigna's algorithms flag incomplete genetic evidence immediately.

2. Wrong Prescriber Type

General practitioners or non-specialists rarely secure approval. Ensure your endocrinologist or metabolic bone specialist submits the request.

3. Missing Adult Step Therapy Documentation

Adults need clear documentation of failed or contraindicated oral phosphate/vitamin D therapy. Don't assume Cigna will accept clinical notes without specific treatment trial details.

4. Concurrent Medication Errors

Failing to attest that phosphate supplements and active vitamin D will be discontinued can trigger automatic denials.

5. Bypassing Express Scripts/Accredo

Crysvita is a specialty medication that must go through Cigna's specialty pharmacy network. Standard retail pharmacies can't process these prescriptions.

Quick Action Plan: Three Steps to Take Today

Step 1: Gather Required Documentation

  • Contact your specialist to obtain genetic testing results (PHEX or FGF23)
  • Request baseline serum phosphorus lab results with reference ranges
  • Collect documentation of any prior phosphate/vitamin D therapy trials (adults)

Step 2: Verify Your Coverage

  • Call Cigna member services to confirm your plan requires PA for Crysvita
  • Verify Express Scripts/Accredo is your specialty pharmacy benefit
  • Check if you have commercial coverage (eligible for PA external review) vs. self-funded employer plan

Step 3: Initiate Prior Authorization

  • Have your specialist submit PA through Express Scripts electronic portal
  • Include all documentation from Step 1 with initial submission
  • Request expedited review if clinically urgent

Pennsylvania External Review Process

If Cigna denies your Crysvita request, Pennsylvania offers a powerful appeals option through the Independent External Review Program.

Timeline and Process

  • Standard Review: 45 days for decision after assignment to independent review organization
  • Expedited Review: 72 hours for urgent cases with physician certification
  • Success Rate: Approximately 50% of appealed denials are overturned

Eligibility Requirements

  • Must exhaust Cigna's internal appeals process first
  • Applies to commercial insurance (not self-funded employer plans)
  • Must request within 4 months of final denial letter

How to File

Submit requests online through the Pennsylvania Insurance Department portal or by mail/fax using official forms. Contact PID Consumer Services at 1-877-881-6388 for assistance.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform can help identify the specific denial basis and draft point-by-point rebuttals aligned to Cigna's own coverage policies, potentially improving your chances in Pennsylvania's external review process.

Resources and Support

Official Sources

Patient Support

  • Ultragenyx Patient Support: 1-844-CRYSVITA
  • Pennsylvania Insurance Department Consumer Services: 1-877-881-6388
  • Pennsylvania Health Law Project for free appeals assistance

Financial Assistance

  • Ultragenyx CrysAssist Patient Support Program
  • State pharmaceutical assistance programs (verify eligibility at pa.gov)

Disclaimer: This information is for educational purposes and doesn't constitute medical advice. Coverage policies and requirements may change. Always verify current requirements with Cigna and consult your healthcare provider for medical decisions. For personalized assistance with appeals, consider consulting with Counterforce Health or other qualified patient advocacy services.

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