By Counterforce Health Team in Evrysdi (risdiplam) —

Do You Qualify for Evrysdi Coverage by Blue Cross Blue Shield of Michigan? Decision Tree & Next Steps

Answer Box: Your Fastest Path to Evrysdi Coverage

Blue Cross Blue Shield of Michigan requires prior authorization for Evrysdi (risdiplam) with specific criteria: confirmed SMA diagnosis via genetic testing, baseline motor function assessment, and specialist involvement. Start today: Download the BCBSM-specific PA form, gather genetic test results and motor function scores, and have your neurologist submit within 5-7 business days. If denied, you have 127 days to file an external review with Michigan DIFS.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible": Your Document Checklist
  4. If "Possibly Eligible": Tests to Request
  5. If "Not Yet": Alternative Pathways
  6. If Denied: Michigan Appeal Process
  7. Coverage Requirements at a Glance
  8. Financial Assistance & Support Programs
  9. FAQ: Common Questions

How to Use This Decision Tree

This guide helps SMA patients and their families navigate Blue Cross Blue Shield of Michigan's (BCBSM) coverage process for Evrysdi. Work through each section based on where you are in your journey—from initial diagnosis to potential appeals.

Before you start: Gather your insurance card, recent clinic notes, and any genetic testing results. If you don't have these, we'll show you what to request.

Eligibility Triage: Do You Qualify?

✅ Likely Eligible If You Have:

  • Confirmed SMA diagnosis (types 1, 2, or 3) via genetic testing showing biallelic SMN1 pathogenic variants
  • Baseline motor function assessment within the last 90 days (CHOP INTEND, HFMSE, or RULM scores)
  • Specialist involvement (neurologist or neuromuscular specialist)
  • Documentation of clinical need (motor decline or lack of improvement with current care)

🟡 Possibly Eligible If You Have:

  • SMA diagnosis but missing recent motor function scores
  • Genetic testing ordered but results pending
  • Previous treatment with Spinraza or consideration for Zolgensma
  • Specialist referral in progress

❌ Not Yet Eligible If You Have:

  • No confirmed SMA diagnosis
  • SMA type 0 or 4 (not FDA-approved indications)
  • Respiratory failure requiring ventilation within 1 month
  • No specialist involvement

If "Likely Eligible": Your Document Checklist

Required Documentation for BCBSM Prior Authorization

Document Type Specific Requirements Where to Obtain
Genetic Testing SMN1 biallelic variants; SMN2 copy number Genetics lab report
Motor Assessment CHOP INTEND (infants), HFMSE (types 2/3), RULM (upper limb) Neurology clinic
Clinical Notes Diagnosis confirmation, symptom progression, treatment history Medical records
Specialist Attestation Neurologist or neuromuscular specialist prescription Provider documentation

Submission Process

  1. Download the PA form: Use the BCBSM-specific Evrysdi form
  2. Complete thoroughly: Include patient demographics, provider NPI, ICD-10 codes (G12.0-G12.1 for SMA)
  3. Submit via:
    • BCBSM provider portal (ereferrals.bcbsm.com)
    • Fax (form-specific number on document)
    • NaviNet for urgent cases
  4. Timeline: 5-7 business days for standard review; 24-48 hours for urgent requests
Tip: Request expedited review if there's clinical urgency. Your doctor must document why delays could harm your health.

If "Possibly Eligible": Tests to Request

Missing Genetic Confirmation?

Contact your neurologist to order:

  • SMN1 gene analysis (deletion/duplication testing)
  • SMN2 copy number determination
  • Results typically available in 2-3 weeks

Need Motor Function Baseline?

Schedule assessment using age-appropriate tools:

  • Infants (0-2 years): CHOP INTEND or HINE
  • Children/Adults (types 2/3): HFMSE or RULM
  • Timeline: Can often be completed at next neurology visit

Tracking Your Progress

  • Keep copies of all test results
  • Document any motor decline or functional changes
  • Maintain communication with your specialist
  • Re-apply timeline: Once you have complete documentation (typically 4-6 weeks)

If "Not Yet": Alternative Pathways

Building Your Case for Future Approval

If diagnosis is unclear:

  • Request referral to neuromuscular specialist
  • Consider genetic counseling consultation
  • Document all SMA-related symptoms and progression

If you have excluded diagnoses:

  • Discuss with your doctor whether Evrysdi might be appropriate off-label
  • Prepare for formulary exception request with strong clinical justification
  • Consider enrollment in clinical trials if available

Preparing Exception Requests

Work with your doctor to document:

  • Why standard SMA treatments aren't suitable
  • Peer-reviewed evidence supporting off-label use
  • Potential benefit based on your specific presentation

If Denied: Michigan Appeal Process

Michigan offers robust appeal rights under the Patient's Right to Independent Review Act. Here's your roadmap:

Level 1: Internal Appeal with BCBSM

  • Deadline: 180 days from denial notice
  • Timeline: 30-60 days for decision; 72 hours for urgent cases
  • How to file: BCBSM member portal, mail, or phone
  • What to include: Denial letter, additional clinical documentation, specialist letter

Level 2: Michigan DIFS External Review

  • Deadline: 127 days from final internal denial
  • Timeline: Up to 60 days (often faster); 72 hours for expedited
  • How to file: Online form or mail to DIFS
  • Requirements: Completed internal appeal, medical necessity justification
Note: For urgent drug cases, expedited external review can be decided in 24-72 hours with physician attestation.

DIFS Contact: 877-999-6442 (M-F, 8am-5pm) for guidance on external review process.

When External Review Decisions Are Binding

If the Independent Review Organization (IRO) approves coverage, BCBSM must comply and cover Evrysdi as directed.

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed
Prior Authorization BCBSM approval before coverage Completed PA form with clinical justification
Genetic Confirmation Biallelic SMN1 variants confirmed Laboratory genetic testing report
Specialist Prescription Neurologist or neuromuscular specialist Provider attestation and prescription
Baseline Assessment Motor function documented pre-treatment CHOP INTEND, HFMSE, or RULM scores
Clinical Benefit Improvement/stabilization for continuation Follow-up motor assessments

Financial Assistance & Support Programs

Manufacturer Support

Patient Advocacy Resources

For patients struggling with coverage, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform helps identify denial reasons and draft point-by-point rebuttals aligned to payer policies.

From our advocates: "We've seen families succeed by submitting motor function scores alongside genetic testing—even when the initial PA seemed overwhelming. One Michigan family's neurologist included HFMSE improvements from physical therapy, which helped demonstrate the potential benefit of Evrysdi. The key is thorough documentation from day one."

FAQ: Common Questions

How long does BCBSM prior authorization take for Evrysdi? Standard review takes 5-7 business days. Urgent cases with physician documentation can be expedited to 24-48 hours.

What if Evrysdi isn't on BCBSM's formulary? Evrysdi requires prior authorization but is typically covered for FDA-approved SMA indications when criteria are met. Non-formulary status would require a formulary exception.

Can I appeal if I'm denied for "not medically necessary"? Yes. This is often the strongest ground for appeal. Work with Counterforce Health or your specialist to provide additional clinical evidence and guideline citations.

Does step therapy apply if I've tried Spinraza? Previous SMA treatment trials may actually support your Evrysdi request if you experienced limited benefit or intolerance. Document these carefully.

What if I need Evrysdi urgently? Request expedited review through your doctor, who must document why delays would jeopardize your health. Michigan's expedited external appeal can decide urgent drug cases in 24-72 hours.

How much does Evrysdi cost without insurance? List pricing can reach approximately $340,000 annually (weight-based dosing). Individual bottles cost around $11,000 per 80 mL. This underscores the importance of securing coverage.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with your specific BCBSM plan and consult your healthcare provider for medical decisions. For official appeal guidance, contact Michigan DIFS at 877-999-6442.

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