By Counterforce Health Team in Voxzogo (vosoritide) —

The Requirements Checklist to Get Voxzogo (vosoritide) Covered by UnitedHealthcare in New Jersey: Forms, Appeals, and Timeline

Quick Answer: Getting Voxzogo Covered in New Jersey

To get Voxzogo (vosoritide) covered by UnitedHealthcare in New Jersey, you need: (1) FGFR3 genetic testing confirming achondroplasia, (2) bone age X-ray showing open epiphyses within 12 months, (3) prescription from a pediatric endocrinologist or geneticist, and (4) 12+ months of baseline growth data. Submit via OptumRx provider portal with complete documentation. If denied, you have 180 days for internal appeals, then external review through New Jersey's IHCAP program. Start the process 60 days before any current authorization expires.

Table of Contents

Who Should Use This Checklist

This guide is for families with children diagnosed with achondroplasia who need Voxzogo (vosoritide) coverage through UnitedHealthcare in New Jersey. You'll also find this helpful if you're a healthcare provider submitting prior authorization requests or appealing denials.

Expected outcome: With complete documentation, initial approvals typically process within 10-15 business days. If denied, New Jersey's robust external review system (IHCAP) overturns approximately 50% of insurance denials when medical necessity is properly documented.

Member & Plan Basics

Coverage Verification

Before starting, confirm these basics:

  • Active UnitedHealthcare coverage in New Jersey
  • Plan type: Commercial, Medicare Advantage, or Medicaid managed care
  • Specialty drug benefits are active (Voxzogo requires OptumRx specialty pharmacy)
  • Deductible status: Specialty medications typically have 25-40% coinsurance after deductible
Tip: Call the member services number on your insurance card and ask specifically about "specialty drug prior authorization requirements" and "OptumRx network status."

Authorization Requirements

Voxzogo requires prior authorization for all UnitedHealthcare plan types in New Jersey. The medication is classified as specialty tier with no generic alternatives available.

Clinical Criteria Requirements

UnitedHealthcare's medical necessity criteria for Voxzogo are strict and non-negotiable:

Core Requirements

  • Age: Patient must be under 18 years old
  • Diagnosis: Confirmed achondroplasia with pathogenic FGFR3 variant
  • Growth plates: Open epiphyses confirmed by bone age X-ray within 12 months
  • Prescriber: Pediatric endocrinologist, geneticist, or achondroplasia specialist
  • Baseline data: Minimum 12 months of height/weight measurements
  • Surgical history: No limb-lengthening surgery within 18 months; none planned during treatment

Dosing Requirements

  • Standard dose: 0.24 mg/kg subcutaneous once daily
  • Weight-based vial selection: Dosing determines specific vial strength needed
  • Administration: Daily subcutaneous injection with rotation of injection sites

Exclusion Criteria

Treatment is contraindicated if patient has:

  • Closed epiphyses (growth plates)
  • Planned limb-lengthening surgery
  • Concurrent growth hormone therapy
  • eGFR <60 mL/min/1.73 m²

Coding & Billing Information

HCPCS Codes

  • J3490: Unclassified drugs (primary)
  • C9399: Unlisted drug or biological (alternative)

NDC Codes by Vial Strength

  • 0.4 mg: NDC 68135-061-00, 68135-070-12, 68135-082-36
  • 0.56 mg: NDC 68135-094-84, 68135-102-43
  • 1.2 mg: NDC 68135-119-66, 68135-130-92, 68135-158-17, 68135-181-93

ICD-10 Diagnosis Code

  • Q77.4: Achondroplasia (required for all submissions)

Documentation Packet

Provider Medical Necessity Letter Must Include:

  1. Patient demographics: Age, weight, height, growth velocity
  2. Diagnosis confirmation: Clinical manifestations and genetic testing results
  3. Treatment history: Previous interventions tried/failed or contraindicated
  4. Clinical rationale: Why Voxzogo is medically necessary now
  5. Monitoring plan: Growth tracking and bone age assessments
  6. Dosing justification: Weight-based calculation (0.24 mg/kg daily)

Required Attachments Checklist:

  • FGFR3 genetic test report showing pathogenic variant
  • Bone age X-ray with radiologist interpretation (within 12 months)
  • Growth chart with 12+ months baseline measurements
  • Specialist consultation note confirming achondroplasia diagnosis
  • Previous therapy documentation (if applicable)
  • Current height/weight measurements and growth velocity calculation
Note: Missing genetic testing is the #1 cause of Voxzogo denials. Ensure the lab report specifically identifies a pathogenic FGFR3 variant.

Submission Process

Step-by-Step Submission:

  1. Verify current PA form version on UnitedHealthcare provider portal
  2. Complete all required fields (incomplete forms trigger automatic denials)
  3. Attach all documentation as single PDF when possible
  4. Submit via OptumRx provider portal (preferred method)
  5. Alternative: Fax to prior authorization department (confirm current fax number)
  6. Record confirmation number and submission date
  7. Set calendar reminder to check status in 7 days

Common Form Errors That Cause Rejections:

  • Missing patient weight for dosing calculation
  • Outdated bone age imaging (>12 months old)
  • Non-specialist prescriber without consultation documentation
  • Incomplete genetic testing results
  • Missing ICD-10 code Q77.4

Specialty Pharmacy Requirements

OptumRx Mandatory Network

UnitedHealthcare requires OptumRx specialty pharmacy for all Voxzogo dispensing. Patients cannot use retail or alternative specialty pharmacies.

Transfer Process:

  1. PA approval triggers automatic OptumRx enrollment
  2. Patient receives welcome call within 48 hours of approval
  3. Injection training scheduled before first shipment
  4. 30-day supply delivered to patient's home
  5. Refill coordination managed by OptumRx clinical team

What OptumRx Provides:

  • Injection training and ongoing support
  • Adherence monitoring and reminders
  • Coordination with prescribing physician
  • Insurance benefits verification
  • Prior authorization renewal management

After Submission: Tracking Your Request

Timeline Expectations:

  • Standard processing: 10-15 business days
  • Expedited review: 72 hours (for urgent cases)
  • Status updates: Available through provider portal
  • Decision notification: Via portal, fax, and mail

What to Track:

  • Confirmation number from submission
  • Status check schedule (every 3-5 business days)
  • Additional information requests from UnitedHealthcare
  • Approval/denial notification date
  • Authorization number (if approved)
  • OptumRx enrollment confirmation
Tip: Start renewal paperwork 60 days before current authorization expires to avoid treatment gaps.

Common Denial Reasons & How to Fix Them

Denial Reason Fix Strategy Required Documentation
Missing genetic testing Submit FGFR3 variant report Lab report with pathogenic mutation identified
Outdated bone age X-ray Order new imaging Bone age X-ray within past 12 months
Non-specialist prescriber Get specialist consultation Pediatric endocrinologist or geneticist evaluation
Insufficient growth data Provide complete growth history 12+ months of height/weight measurements
Closed epiphyses concern Submit current bone age Recent X-ray confirming open growth plates

Medical Necessity Appeal Language:

"Voxzogo (vosoritide) is the only FDA-approved treatment for achondroplasia in pediatric patients with open epiphyses. The patient has confirmed achondroplasia with pathogenic FGFR3 variant [specify], open growth plates documented by bone age X-ray dated [date], and meets all FDA labeling criteria for treatment."

Appeals Process in New Jersey

Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific requirements.

Internal Appeals (UnitedHealthcare):

  • Level 1: 15-30 days (72 hours if expedited)
  • Level 2: 15-30 days (72 hours if expedited)
  • Filing deadline: 180 days from denial notice
  • Submission: Member/provider portal or written request

External Review (IHCAP):

If internal appeals fail, New Jersey's Independent Health Care Appeals Program provides binding external review:

  • Filing deadline: 120-180 days from final internal denial
  • Processing entity: Maximus Federal Services
  • Cost: Free to patients
  • Timeline: 45 days standard, 48 hours expedited
  • Success rate: ~50% favor patients
  • Contact: 1-888-393-1062
Important: IHCAP decisions are binding. If independent medical reviewers determine Voxzogo is medically necessary, UnitedHealthcare must provide coverage.

When to Request Expedited Review:

  • Current authorization expires within 15 days
  • Treatment delay would cause significant harm
  • Urgent medical situation documented by physician

Printable Checklist

Before You Start:

  • Confirm active UnitedHealthcare coverage in New Jersey
  • Verify OptumRx specialty pharmacy benefits
  • Identify pediatric endocrinologist or geneticist prescriber

Required Documentation:

  • FGFR3 genetic test confirming pathogenic variant
  • Bone age X-ray showing open epiphyses (within 12 months)
  • Growth chart with 12+ months baseline data
  • Specialist medical necessity letter
  • Current height/weight and dosing calculation
  • ICD-10 code Q77.4 (achondroplasia)

Submission Steps:

  • Complete current PA form version
  • Attach all documentation as PDF
  • Submit via OptumRx provider portal
  • Record confirmation number and date
  • Set status check reminders

If Denied:

  • File Level 1 appeal within 180 days
  • Include additional clinical documentation
  • Request expedited review if urgent
  • Prepare for Level 2 appeal if needed
  • Consider IHCAP external review after internal appeals

From our advocates: We've seen families successfully obtain Voxzogo coverage after initial denials by ensuring genetic testing clearly identifies the specific FGFR3 pathogenic variant and submitting recent bone age imaging with detailed radiologist interpretation. Complete documentation upfront prevents most common denial reasons.

Getting Voxzogo covered requires thorough preparation, but New Jersey patients have strong appeal rights if initially denied. Counterforce Health's platform can help analyze denial letters and draft targeted appeals that address UnitedHealthcare's specific coverage criteria using the right clinical evidence and procedural requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and plan terms. Consult with your healthcare provider and insurance plan for guidance specific to your situation. For additional help with insurance appeals in New Jersey, contact the NJ Department of Banking and Insurance Consumer Hotline at 1-800-446-7467.

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