By Counterforce Health Team in Strensiq (asfotase alfa) —

Work With Your Doctor to Get Strensiq (asfotase alfa) Approved by Blue Cross Blue Shield in Texas: Complete Provider Collaboration Guide

Answer Box: Getting Strensiq Approved in Texas

Blue Cross Blue Shield of Texas requires prior authorization for Strensiq (asfotase alfa) with strict pediatric-onset hypophosphatasia criteria. To get approved: (1) Confirm your doctor has genetic testing (ALPL mutation) and low alkaline phosphatase labs, (2) Submit comprehensive medical records showing onset before age 18, and (3) Include specialist consultation documentation. Start today by requesting your complete medical file and scheduling time with your doctor to review BCBSTX's specific PA criteria. Appeals must be filed within 180 days, with external review available through the Texas Department of Insurance.

Table of Contents

  1. Set Your Goal: Understanding BCBS Requirements
  2. Visit Preparation: What to Bring Your Doctor
  3. Building Your Evidence Kit
  4. Medical Necessity Letter Structure
  5. Supporting Your Doctor in Peer-to-Peer Reviews
  6. After Your Visit: Documentation Strategy
  7. Respectful Persistence and Follow-Up
  8. Texas Appeals Process
  9. Cost-Saving Resources
  10. FAQ

Set Your Goal: Understanding BCBS Requirements

Your partnership with your doctor centers on meeting Blue Cross Blue Shield of Texas's specific criteria for Strensiq approval. According to BCBSTX's clinical guidelines, you need to demonstrate:

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Pediatric-onset HPP Symptoms began before age 18 Medical records, growth charts
Genetic confirmation ALPL gene mutation identified Genetic test results
Low alkaline phosphatase Below age/gender reference range Lab reports
Specialist involvement Endocrinologist or consultation Referral notes, specialist reports
Clinical response Documented improvement on therapy Follow-up visits, imaging
FDA-compliant dosing Within 6-9 mg/kg/week limits Weight-based calculations
Note: BCBS of Texas covers 44% of the commercial insurance market in the state, making their specific requirements critical to understand.

Your goal is to work with your doctor to compile bulletproof documentation that addresses each requirement. This isn't just about having hypophosphatasia—it's about proving you meet their exact definition of coverage-eligible HPP.

Visit Preparation: What to Bring Your Doctor

Come to your appointment prepared to help your doctor understand your complete HPP story. Gather these materials beforehand:

Your Symptom Timeline

  • Age at first symptoms (this is crucial—must be before 18)
  • Early manifestations: bone pain, fractures, dental problems, muscle weakness
  • Growth patterns: height/weight charts showing failure to thrive
  • Respiratory issues: if applicable, any breathing difficulties

Previous Treatments Tried

  • Supportive care: physical therapy, orthopedic interventions
  • Medications attempted: vitamin D, calcium, bisphosphonates (and why they failed)
  • Side effects experienced: document any intolerances

Functional Impact Notes

Write a one-page summary of how HPP affects your daily life. Include:

  • Activities you can't do
  • Pain levels and frequency
  • Impact on work, school, or family life
  • Quality of life changes
Tip: Bring a trusted family member who witnessed your early symptoms—their observations can provide valuable context for pediatric-onset documentation.

Building Your Evidence Kit

Work with your doctor's office to compile a comprehensive evidence package:

Essential Laboratory Evidence

  • Alkaline phosphatase levels over time (must show persistent low values)
  • TNSALP substrates: PLP, PEA, PPi if available
  • Genetic testing: ALPL mutation analysis results
  • Bone markers: if tested, osteocalcin, bone-specific ALP

Imaging Documentation

  • Skeletal X-rays: showing rickets, fractures, or bone deformities
  • Bone density scans: if performed
  • Growth charts: demonstrating failure to thrive patterns

Clinical Guidelines Support

Your doctor should reference these in your medical necessity letter:

Medical Necessity Letter Structure

Your doctor's letter of medical necessity is the cornerstone of your approval. Here's what it must include:

Essential Components Checklist

Patient Information Section:

  • Full name, date of birth, insurance ID
  • Diagnosis with ICD-10 code (E83.30 - Disorder of phosphorus metabolism)
  • Date of symptom onset (before age 18)

Clinical Rationale Section:

  • ALPL genetic mutation details
  • Alkaline phosphatase lab values with reference ranges
  • Radiographic findings consistent with HPP
  • Specialist consultation documentation

Treatment History:

  • Previous therapies attempted and outcomes
  • Why alternatives are inappropriate or ineffective
  • Current clinical status without Strensiq

Dosing Justification:

  • Patient weight and calculated dose
  • Confirmation dose is within FDA guidelines (6-9 mg/kg/week)
  • Administration plan and monitoring strategy
From our advocates: "We've seen the strongest approvals when doctors include before-and-after imaging in their letters. One family's endocrinologist attached X-rays showing bone healing after three months of Strensiq, which helped secure long-term coverage during the annual review."

Counterforce Health specializes in helping families and doctors craft these comprehensive medical necessity letters, turning insurance denials into targeted, evidence-backed appeals that align with payer requirements.

Supporting Your Doctor in Peer-to-Peer Reviews

If your initial request is denied, BCBS may offer a peer-to-peer review—a phone call between your doctor and their medical director. Here's how to help:

Preparation Support You Can Provide

Availability Windows:

  • Ask your doctor's preferred times for P2P calls
  • Offer to reschedule your own appointments to accommodate
  • Provide after-hours contact if the situation is urgent

Concise Case Summary: Create a one-page bullet-point summary:

  • Age at symptom onset
  • Key genetic and lab findings
  • Failed alternative treatments
  • Current functional limitations
  • Risks of delaying treatment

Key Talking Points for Your Doctor

  • Emphasize Strensiq is the only FDA-approved treatment for pediatric-onset HPP
  • Reference your specific ALPL mutation and clinical phenotype
  • Highlight risks of untreated HPP: fractures, respiratory failure, premature death
  • Confirm dosing is within FDA-approved limits

After Your Visit: Documentation Strategy

Maximize the value of every medical encounter:

What to Save

  • After-visit summaries from your patient portal
  • Lab orders and results (request copies immediately)
  • Imaging reports and actual images when possible
  • Prescription records showing Strensiq orders
  • Communication logs with insurance companies

Patient Portal Messaging

Use your doctor's secure messaging system to:

  • Request copies of letters sent to insurance
  • Ask for updates on PA status
  • Share any new symptoms or concerns
  • Confirm receipt of insurance communications

Creating Your Master File

Organize everything chronologically:

  1. Initial diagnosis and genetic testing
  2. Treatment attempts and failures
  3. Strensiq prescription and PA submission
  4. Insurance correspondence and appeals
  5. Clinical response documentation

Respectful Persistence and Follow-Up

Getting Strensiq approved often requires sustained advocacy. Here's how to stay engaged without overwhelming your healthcare team:

Follow-Up Cadence

  • Week 1-2: Confirm PA submission and ask for reference number
  • Week 3: Check status and offer additional documentation
  • Week 4+: If no response, request peer-to-peer review

Escalation Strategy

If your doctor seems overwhelmed:

  1. Offer to contact Counterforce Health for specialized appeals support
  2. Ask if a patient navigator or social worker can help coordinate
  3. Request referral to an HPP specialist for additional support
  4. Consider involving Alexion's patient access program

Professional Communication

  • Always thank your healthcare team for their efforts
  • Provide organized, relevant information only
  • Respect office policies about communication frequency
  • Offer to help with administrative tasks when appropriate

Texas Appeals Process

If your initial request is denied, Texas law provides clear appeal rights:

Internal Appeal Timeline

  • Deadline to file: 180 days from denial notice
  • BCBS decision time: 30 days (pre-service) or 60 days (post-service)
  • Expedited appeals: 72 hours if health is at risk

External Review (IRO)

  • Eligibility: After internal appeal denial
  • Deadline: 4 months from final internal denial
  • Decision time: 20 days standard, 5 days expedited
  • Contact: Texas Department of Insurance at 1-866-554-4926

Required Documentation

  • Original denial letter
  • Medical records supporting necessity
  • Doctor's attestation of medical necessity
  • Any additional clinical evidence
Important: Keep detailed records of all communications, including dates, names, and reference numbers.

Cost-Saving Resources

While working toward insurance approval, explore these options:

Manufacturer Support

  • Alexion Access Navigator: Patient assistance programs
  • Copay assistance: May reduce out-of-pocket costs
  • Bridge programs: Temporary coverage during appeals

Foundation Grants

  • Patient Advocate Foundation
  • National Organization for Rare Disorders (NORD)
  • HealthWell Foundation (when available)

State Programs

Texas residents may qualify for additional support through state disability services or rare disease programs.

FAQ

How long does BCBS PA take in Texas? Standard prior authorization decisions are made within 30 days for pre-service requests. Expedited reviews take 72 hours if your doctor certifies that delay could harm your health.

What if Strensiq isn't on my formulary? Request a formulary exception through your doctor. BCBS must consider exceptions when no covered alternatives are appropriate for your condition.

Can I get an expedited appeal? Yes, if your doctor documents that waiting for standard review timelines could seriously jeopardize your health. Both internal and external appeals can be expedited.

Does step therapy apply to Strensiq? Generally no, since Strensiq is the only FDA-approved disease-modifying therapy for pediatric-onset HPP. However, BCBS may require documentation of supportive care attempts.

What if my doctor isn't familiar with HPP? Request referral to a pediatric endocrinologist or metabolic specialist. BCBS criteria specifically mention specialist involvement as a requirement.

How much does Strensiq cost without insurance? Cash prices can exceed $10,000 per vial, with annual costs potentially reaching $500,000-$4.9 million depending on weight and dosing. This makes insurance coverage essential.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for guidance specific to your situation. Insurance policies and requirements may vary by plan type and can change over time.

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