By Counterforce Health Team in Evrysdi (risdiplam) —

Complete Guide to Getting Evrysdi (Risdiplam) Covered by UnitedHealthcare in Texas: Prior Authorization Requirements and Appeals Process

Quick Answer: Getting Evrysdi Approved by UnitedHealthcare in Texas

UnitedHealthcare requires prior authorization for Evrysdi (risdiplam) with specific criteria: confirmed 5q SMA genetic mutation, baseline motor function assessment, and no concurrent Spinraza therapy. Submit via the UnitedHealthcare Provider Portal with genetic testing results and neurologist consultation. If denied, Texas law provides strong appeal rights including external review through an Independent Review Organization. Start by gathering genetic confirmation, motor function scores, and insurance details today.

Table of Contents

  1. Who Should Use This Guide
  2. UnitedHealthcare Coverage Requirements
  3. Clinical Documentation Checklist
  4. Prior Authorization Submission Process
  5. Specialty Pharmacy Network
  6. Common Denial Reasons & Solutions
  7. Appeals Process in Texas
  8. Cost Assistance Programs
  9. Frequently Asked Questions

Who Should Use This Guide

This guide is for patients with spinal muscular atrophy (SMA) and their families seeking Evrysdi coverage through UnitedHealthcare in Texas, as well as healthcare providers submitting prior authorization requests.

Use this guide if you:

  • Have a confirmed SMA diagnosis and need Evrysdi coverage
  • Received a UnitedHealthcare denial for Evrysdi
  • Are switching from Spinraza or considering treatment options
  • Need to appeal a coverage decision in Texas

Expected outcome: With proper documentation, most medically appropriate Evrysdi requests are approved. Counterforce Health helps patients and providers navigate complex prior authorization requirements by analyzing denial letters and crafting targeted, evidence-backed appeals that address specific payer criteria.

UnitedHealthcare Coverage Requirements

Coverage at a Glance

Requirement Details Documentation Needed Source
Prior Authorization Required for all plans PA form submission UHC PA Policy
Diagnosis Confirmed SMA Genetic testing results UHC PA Policy
Genetic Testing 5q SMA mutation/deletion Lab report UHC PA Policy
Specialist Requirement Neurologist consultation Provider attestation UHC PA Policy
Baseline Assessment Motor function scores HINE, HFMSE, or RULM UHC PA Policy
Concurrent Therapy No Spinraza allowed Medical records UHC PA Policy

Initial Authorization Criteria (12 months)

UnitedHealthcare approves Evrysdi if all criteria are met:

  • Confirmed diagnosis of spinal muscular atrophy
  • Medical records documenting homozygous deletion or compound heterozygous mutation of the SMN1 gene
  • Patient not receiving concurrent SMN-modifying therapy (Spinraza/nusinersen)
  • No prior gene therapy (Zolgensma), OR prior Zolgensma with documented functional decline
  • Baseline motor assessment using age-appropriate tools
  • Prescribed by or in consultation with a neurologist expert in SMA

Reauthorization Requirements

For continued coverage, submit documentation showing positive clinical response compared to baseline using validated motor function scales.

Clinical Documentation Checklist

Genetic Testing Requirements

✓ SMN1 gene analysis confirming homozygous deletion or compound heterozygous mutation
✓ SMN2 copy number (helpful for severity assessment)
✓ Laboratory report from qualified genetic testing facility
✓ Genetic counseling documentation (recommended)

Tip: Order genetic testing through established labs like Athena Diagnostics or similar facilities that provide comprehensive SMA panels including SMN1/SMN2 analysis.

Motor Function Assessment

Choose age-appropriate baseline assessment:

Infants (SMA Type 1):

  • CHOP-INTEND (Children's Hospital of Philadelphia Infant Test)
  • Minimum score documentation required

Children and Adults:

  • HFMSE (Hammersmith Functional Motor Scale Expanded)
  • RULM (Revised Upper Limb Module)
  • MFM-32 (Motor Function Measure)
  • 6-minute walk test (if ambulatory)

ICD-10 Diagnosis Codes

Primary codes for billing and authorization:

  • G12.0: Infantile spinal muscular atrophy, type I (Werdnig-Hoffmann)
  • G12.1: Other inherited spinal muscular atrophy (types II and III)

Avoid G12.9 (unspecified) when possible—use specific type codes.

NDC Numbers for Billing

Formulation NDC Number
Oral solution (0.75 mg/mL) 50242-0175-07
Tablets (5 mg) 50242-0202-01

HCPCS Code: Use J8499 (oral non-chemotherapeutic drug) as Evrysdi has no permanent J-code.

Prior Authorization Submission Process

Step-by-Step: Fastest Path to Approval

  1. Gather Required Documents (Patient/Clinic)
    • Insurance card and member ID
    • Genetic testing results
    • Baseline motor function scores
    • Neurologist consultation notes
  2. Complete PA Form (Provider)
  3. Submit via Provider Portal (Provider)
    • Access UnitedHealthcare Provider Portal
    • Alternative: Call 866-889-8054
    • Expected timeline: Same-day submission
  4. Track Submission Status (Provider/Patient)
    • Standard review: 72 hours
    • Expedited review: 24 hours (urgent cases)
    • Follow up if no response within timeframe
  5. Coordinate with Specialty Pharmacy (Patient)
    • Accredo (preferred vendor): 855-525-7995
    • Verify insurance and delivery details
    • Expected timeline: 3-5 business days for first shipment
Note: Counterforce Health can help streamline this process by ensuring your prior authorization includes all required documentation and meets UnitedHealthcare's specific criteria before submission.

Specialty Pharmacy Network

UnitedHealthcare designates Accredo as the preferred specialty pharmacy for Evrysdi in Texas and nationwide.

Accredo Contact Information:

Shipment Process:

  1. Accredo contacts patient to welcome and confirm insurance
  2. Pharmacy verifies delivery address and preferred timing
  3. Monthly shipments delivered directly to patient
  4. Patient must answer pharmacy calls to avoid delays

Alternative Support:

  • MySMA Support: 833-387-9734
  • Genentech Patient Foundation: 877-436-3683

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Missing genetic confirmation Submit SMN1 gene test results Laboratory report showing homozygous deletion
Insufficient motor function data Provide baseline assessment scores CHOP-INTEND, HFMSE, RULM, or MFM-32 results
Concurrent Spinraza therapy Document therapy discontinuation Medical records showing Spinraza cessation
Prior Zolgensma without decline Show functional deterioration Motor assessment comparison pre/post gene therapy
Non-specialist prescriber Obtain neurologist consultation Specialist evaluation and recommendation

Appeals Process in Texas

Texas provides strong patient rights for insurance appeals with specific timelines and external review options.

Internal Appeals (First Level)

Timeline: File within 180 days of denial
Decision: 30 days for pre-service requests
How to file: UnitedHealthcare member portal or written request

External Review (Independent)

When available: After internal appeal denial based on medical necessity
Timeline: File within 4 months of final internal denial
Decision: 20 days (5 days for urgent cases)
Cost: Paid by UnitedHealthcare

Texas Department of Insurance Support:

  • Consumer helpline: 1-800-252-3439
  • IRO information: 1-866-554-4926
  • Website: tdi.texas.gov

Expedited Appeals

Available for urgent medical situations where delay could jeopardize health. Both internal and external reviews can be expedited concurrently.

Important: ERISA self-funded employer plans follow federal appeal rules, not Texas state requirements. Check your plan type on your insurance card.

Cost Assistance Programs

Manufacturer Support

Genentech Patient Foundation

  • Phone: 877-436-3683
  • Website: genentech-access.com
  • Eligibility: Income-based assistance for uninsured/underinsured patients

MySMA Support

  • Phone: 833-387-9734
  • Services: Insurance navigation, copay assistance, financial resources

Additional Resources

  • Patient Access Network (PAN) Foundation: panfoundation.org
  • National Organization for Rare Disorders (NORD): rarediseases.org
  • Muscular Dystrophy Association: mda.org

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take for Evrysdi in Texas? Standard review takes up to 72 hours. Expedited review for urgent cases is completed within 24 hours.

What if Evrysdi is not on my formulary? Submit a formulary exception request with medical necessity documentation. Your doctor can request coverage for non-formulary medications when medically appropriate.

Can I get expedited approval if my child has rapidly progressing SMA? Yes. Request expedited prior authorization and appeals when delays could jeopardize health. Document the urgency in your submission.

Does step therapy apply if I tried Spinraza outside Texas? Treatment history from any location counts. Document prior therapies, outcomes, and reasons for discontinuation or switch.

What happens if UnitedHealthcare denies my appeal? You can request external review through Texas's Independent Review Organization system. This provides an impartial medical review at no cost to you.

How do I find a neurologist experienced with SMA in Texas? Contact the Muscular Dystrophy Association at mda.org or Cure SMA at curesma.org for specialist referrals.

From Our Advocates

"We've seen families succeed by gathering all genetic testing and motor function documentation before submitting their first prior authorization request. Having complete clinical records upfront prevents the back-and-forth that delays approval. One Texas family received approval within 48 hours because their neurologist included detailed baseline scores and genetic confirmation in the initial submission."

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan. Always verify current requirements with UnitedHealthcare and consult healthcare providers for medical decisions.

For additional assistance with insurance denials and appeals in Texas, contact the Texas Department of Insurance at 1-800-252-3439 or visit tdi.texas.gov.

Sources & Further Reading

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