Crysvita® (burosumab) (Revised)

REQUIREMENTS: - Immediately: Billing and pharmacy teams must verify prior authorization is obtained BEFORE dispensing Crysvita for all XLH and TIO patients. Add this medication to the prior auth requirement list in billing software for Kentucky and South Carolina Medicaid and Medicare plans. - Ensure providers submit documentation with prior auth requests including: (1) serum FGF23 level >30 pg/mL or positive PHEX test, (2) reduced TmP/GFR ratio, (3) clinical signs/symptoms (rickets, growth impairment, musculoskeletal pain for XLH; muscle weakness, bone pain, fatigue for TIO), and (4) for TIO cases, confirmation that tumor cannot be curatively resected. - Verify patient serum phosphorus levels are BELOW age-appropriate normal ranges (per policy chart) before dispensing - claims will be denied if levels are within or above normal range. - Flag for denial any claims where patient has severe renal impairment, end-stage renal disease, or is on concomitant oral phosphate and/or active vitamin D analogs (contraindications). - Update approval duration fields in billing system to reflect plan year initial and renewal durations (currently blank in policy - contact Humana for specific durations). - Route all Crysvita requests to prior authorization team with primary focus on Kentucky and South Carolina Medicaid and Medicare members.