By Counterforce Health Team in Voxzogo (vosoritide) —

The Complete Requirements Checklist to Get Voxzogo (vosoritide) Covered by Blue Cross Blue Shield in Pennsylvania

Answer Box: Getting Voxzogo Covered by Blue Cross Blue Shield in Pennsylvania

To get Voxzogo (vosoritide) covered by Blue Cross Blue Shield in Pennsylvania: 1) Confirm your child meets FDA criteria (achondroplasia, age ≥2 years, open growth plates), 2) Have your pediatric specialist submit prior authorization with genetic testing results and growth plate imaging, 3) If denied, use Pennsylvania's new Independent External Review program—it overturned 50% of denials in 2024. Start today by calling the member services number on your insurance card to request prior authorization forms. Most approvals require 7-15 business days.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria for Voxzogo Coverage
  4. Coding and Documentation Requirements
  5. Complete Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Requirements
  8. After Submission: What to Expect
  9. Common Denial Reasons & How to Fix Them
  10. Pennsylvania Appeals Process
  11. Quick Reference Checklist

Who Should Use This Checklist

This guide is for Pennsylvania families whose child has achondroplasia and needs Voxzogo (vosoritide) coverage through any Blue Cross Blue Shield plan—including Highmark Blue Shield (western PA) and Independence Blue Cross (Philadelphia region).

Expected outcome: With complete documentation, most prior authorizations are approved within 7-15 business days. If denied, Pennsylvania's new external review program has a 50% success rate for overturning denials.

When to start: Begin this process 2-3 weeks before your child needs to start treatment, as specialty pharmacy coordination adds extra time.

Member & Plan Basics

Verify Your Coverage Status

Before starting, confirm these basics by calling the member services number on your Blue Cross Blue Shield ID card:

  • Active coverage for your child
  • Plan type (HMO, PPO, or high-deductible health plan)
  • Specialty drug benefits and whether prior authorization is required
  • Deductible status and out-of-pocket maximums
Tip: Ask specifically about "specialty injectable medications" rather than just "prescription drugs"—the coverage rules often differ.

Blue Cross Blue Shield Plans in Pennsylvania

Pennsylvania has multiple Blue Cross Blue Shield plans with varying policies:

Clinical Criteria for Voxzogo Coverage

FDA-Approved Indication

Voxzogo is FDA-approved for achondroplasia in pediatric patients ≥2 years old with open epiphyses. The FDA expanded the age indication from ≥5 to ≥2 years in 2023.

Medical Necessity Requirements

Your child must meet these criteria:

Diagnosis Requirements:

  • Confirmed achondroplasia with pathogenic FGFR3 variant
  • Genetic testing report documenting the specific mutation
  • Clinical diagnosis consistent with achondroplasia

Age and Growth Requirements:

  • Age ≥2 years at treatment initiation
  • Open growth plates confirmed by imaging (X-ray or MRI)
  • Baseline growth velocity measurements

Prescriber Requirements:

  • Prescription from pediatric endocrinologist or geneticist
  • Specialist familiar with achondroplasia management

Dosing and Duration

  • Standard dose: 0.24 mg/kg subcutaneous injection once daily
  • Duration: Treatment continues while growth plates remain open
  • Reauthorization: Typically required annually with growth data

Coding and Documentation Requirements

ICD-10 Diagnosis Codes

Primary diagnosis:

  • Q77.4 - Achondroplasia

Supporting codes (if applicable):

  • Z87.820 - Personal history of osteoporosis fractures
  • M79.89 - Other specified soft tissue disorders

Drug Identification

  • Generic name: vosoritide
  • Brand name: Voxzogo
  • NDC numbers: (verify current NDC with specialty pharmacy)
  • Strength: 0.4 mg, 0.56 mg, 1.2 mg vials

Complete Documentation Packet

Provider Note Requirements

Your specialist's note must include:

Patient History:

  • Detailed growth history with measurements
  • Previous treatments attempted
  • Family history of achondroplasia
  • Current symptoms and functional limitations

Clinical Assessment:

  • Physical examination findings
  • Growth velocity calculations
  • Bone age assessment
  • Review of systems

Treatment Plan:

  • Rationale for Voxzogo therapy
  • Dosing calculations based on weight
  • Monitoring plan
  • Expected outcomes

Letter of Medical Necessity Components

A comprehensive letter should address:

  1. Patient identification and diagnosis
  2. Clinical rationale for treatment
  3. FDA approval status and on-label use
  4. Alternative treatments considered and why they're insufficient
  5. Expected benefits and monitoring plan
  6. Literature support with relevant citations

Required Attachments

Essential documents:

  • Genetic testing report confirming FGFR3 mutation
  • Growth plate imaging (X-ray showing open epiphyses)
  • Growth charts with velocity calculations
  • Specialist consultation notes
  • Previous treatment records (if any)

Supporting documents:

  • Laboratory results (baseline chemistry, bone markers)
  • Bone age studies
  • Family history documentation
  • Patient/parent consent forms

Submission Process

Prior Authorization Forms

For Highmark Blue Shield:

For Independence Blue Cross:

Submission Methods

Electronic submission (preferred):

  • Provider portal upload with all attachments
  • Confirmation number provided immediately

Fax submission:

  • Verify current fax numbers with your plan
  • Include cover sheet with member ID and provider information
  • Request fax confirmation receipt

Timeline Expectations

  • Standard review: 7-15 business days
  • Expedited review: 2-3 business days (if urgent medical need)
  • Additional information requests: May extend timeline by 5-10 days

Specialty Pharmacy Requirements

Distribution Network

Voxzogo is available only through specialty pharmacies. Blue Cross Blue Shield plans typically have preferred networks, but specific vendors vary by plan.

To identify your plan's preferred specialty pharmacy:

  • Call member services
  • Ask for "specialty pharmacy network for injectable medications"
  • Verify coverage and copay information

Coordination Steps

  1. Provider prescription sent to specialty pharmacy
  2. Insurance verification by pharmacy
  3. Patient enrollment and education
  4. Delivery coordination (refrigerated shipping required)
  5. Ongoing refill management
Note: BioMarin RareConnections provides support for specialty pharmacy coordination and can help navigate insurance requirements.

After Submission: What to Expect

Tracking Your Request

Record these details:

  • Prior authorization reference number
  • Submission date and method
  • Contact person at your provider's office
  • Expected decision timeline

Status checks:

  • Call member services weekly for updates
  • Provider office should also monitor status
  • Request written confirmation of any verbal approvals

Possible Outcomes

Approval:

  • Written authorization letter with effective dates
  • Coverage details and any limitations
  • Specialty pharmacy can proceed with dispensing

Denial:

  • Detailed denial letter with specific reasons
  • Instructions for appeal process
  • Timeline for submitting appeals

Request for additional information:

  • Specific documents or clarifications needed
  • Deadline for providing information
  • Contact information for questions

Common Denial Reasons & How to Fix Them

Top 5 Denial Reasons and Solutions

Denial Reason How to Fix Required Documentation
Missing genetic testing Submit FGFR3 variant confirmation Laboratory report with specific mutation identified
Growth plates not confirmed open Provide current imaging X-ray or MRI with radiologist interpretation
Non-specialist prescriber Transfer care or get consultation Pediatric endocrinologist or geneticist evaluation
Insufficient growth data Submit comprehensive growth history Growth charts with velocity calculations over ≥6 months
Age criteria not met Verify FDA labeling Documentation that child is ≥2 years old

Prevention Tips

Before submission:

  • Review all requirements with your specialist
  • Ensure genetic testing is recent (within 2 years)
  • Confirm prescriber meets plan requirements
  • Verify all forms are current versions

Documentation quality:

  • Use clear, legible copies
  • Include member ID on every page
  • Organize documents logically
  • Provide cover sheet summarizing contents

Pennsylvania Appeals Process

Internal Appeals (First Level)

If your initial request is denied:

Timeline: Submit within 60 days of denial letter Process:

  • Use your plan's appeal form
  • Include additional supporting documentation
  • Request peer-to-peer review if available

Expected timeline: 15-30 days for standard review, 72 hours for expedited

Pennsylvania's Independent External Review

Pennsylvania launched a new external review program in January 2024 with impressive results: 50% of appeals were successful in the first year.

Eligibility: After completing internal appeals and receiving a Final Adverse Benefit Determination Timeline: Must request within 4 months of final denial Process: Submit online through PA Insurance Department

Review timeline:

  • Standard: 45 days from assignment to decision
  • Expedited: 72 hours for urgent cases

Success factors:

  • Complete medical records
  • Peer-reviewed literature supporting treatment
  • Clear documentation of medical necessity
  • Evidence that denial was inappropriate
Pennsylvania residents: The state's Consumer Assistance Program provides free help with appeals. Contact the Pennsylvania Health Law Project for assistance.

Quick Reference Checklist

Before You Start

  • Verify active Blue Cross Blue Shield coverage
  • Confirm plan requires prior authorization
  • Identify your specific Blue Cross Blue Shield plan (Highmark, Independence, etc.)
  • Ensure prescriber is pediatric specialist

Required Documentation

  • Genetic testing confirming FGFR3 achondroplasia
  • Growth plate imaging showing open epiphyses
  • Growth charts with velocity calculations
  • Specialist consultation notes
  • Letter of medical necessity
  • Prior authorization form (current version)

Submission

  • Submit via preferred method (portal vs. fax)
  • Include all required attachments
  • Request confirmation of receipt
  • Record reference number and submission date

Follow-Up

  • Check status weekly
  • Respond promptly to information requests
  • Coordinate with specialty pharmacy once approved
  • Prepare appeal documents if denied

Sources & Further Reading

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for patients needing specialty medications like Voxzogo. Our platform analyzes denial letters and payer policies to create targeted, evidence-backed appeals that address the specific reasons for denial. We help patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and improve approval rates through data-driven advocacy.

This guide is for informational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently—always verify current requirements with your specific Blue Cross Blue Shield plan. For personalized assistance with appeals, consult with patient advocacy organizations or consider working with specialists like Counterforce Health who focus on insurance coverage for rare disease treatments.

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