By Counterforce Health Team in Evrysdi (risdiplam) —

Do You Qualify for Evrysdi (Risdiplam) Coverage by Humana in Ohio? Complete Decision Tree & Appeals Guide

Quick Answer: Evrysdi (Risdiplam) Coverage by Humana in Ohio

Most likely eligible if you have: Genetic confirmation of 5q SMA (Types I-III), baseline motor assessment, and prescription from a neurologist. First step today: Have your doctor gather genetic testing reports and motor function documentation, then submit prior authorization through Humana's provider portal. Timeline: 72 hours for standard requests, 24 hours expedited. If denied: Ohio offers external review within 180 days with 53% overturn rate through independent medical experts.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Assessment
  3. If You're Likely Eligible
  4. If You're Possibly Eligible
  5. If You're Not Yet Eligible
  6. If Your Request Is Denied
  7. Appeals Playbook for Ohio
  8. Common Denial Reasons & Solutions
  9. Frequently Asked Questions

How to Use This Decision Tree

This guide helps you determine your likelihood of getting Evrysdi (risdiplam) covered by Humana in Ohio and provides specific next steps based on your situation. Work through the eligibility assessment below, then jump to the section that matches your result.

Before you start, gather:

  • Insurance card and member ID
  • Genetic testing results
  • Motor function assessments
  • Previous SMA treatment records
  • Current neurologist contact information

Eligibility Assessment

Answer these questions to determine your coverage pathway:

Diagnosis Requirements ✓

  • Genetic confirmation of 5q SMA with bi-allelic pathogenic variants in SMN1 gene
  • SMA Type I, II, or III diagnosis confirmed by neurologist
  • Age 2 months or older
  • SMN2 copy number documented (1-4 copies typically eligible)

Clinical Requirements ✓

  • Baseline motor assessment using validated tools (CHOP-INTEND, HFMSE, RULM, or 6MWT)
  • Not dependent on invasive ventilation or tracheostomy
  • Some functional upper extremity use (Types II-III)
  • Prescription from neurologist experienced in SMA treatment

Treatment History ✓

  • No previous Zolgensma (gene therapy) treatment
  • Not currently on Spinraza or other SMA treatments
  • Documentation of treatment goals and monitoring plan

Results:

If You're Likely Eligible

You have strong documentation supporting coverage. Here's your fastest path to approval:

Document Checklist for Submission

Required Documentation:

  • Genetic testing report confirming SMN1/SMN2 status
  • Baseline motor function assessment (age-appropriate validated tool)
  • Neurologist prescription with treatment justification
  • Patient weight documentation (if no gastrostomy tube)
  • Treatment goals and monitoring plan

Supporting Documents:

  • Previous therapy records (if applicable)
  • Respiratory infection history (past year)
  • Current functional status notes

Submission Process

  1. Contact your neurologist to compile all required documentation
  2. Submit prior authorization through Humana's provider portal
  3. Expect response within 72 hours (standard) or 24 hours (expedited)
  4. Track your request using Humana's online portal or member services
Tip: Request expedited review if treatment delay could worsen your condition. Include a letter from your neurologist explaining the urgency.

If You're Possibly Eligible

You meet basic requirements but need additional documentation or testing:

Tests to Request from Your Doctor

Missing genetic testing:

  • SMN1 gene deletion/mutation analysis
  • SMN2 copy number quantification
  • Request referral to genetic counselor if needed

Missing motor assessments:

  • Age-appropriate validated assessment (verify with source linked below)
  • Baseline functional status documentation
  • Treatment response monitoring plan

Timeline for Reapplication

  • Genetic testing results: 2-4 weeks
  • Motor assessments: 1-2 weeks
  • Complete documentation: Plan to resubmit within 30-45 days

Track your progress and maintain communication with your neurologist's office to ensure timely completion.

If You're Not Yet Eligible

Don't lose hope. Here are alternatives and preparation steps:

Alternative Treatments to Discuss

  • Spinraza (nusinersen) - intrathecal injection therapy
  • Supportive care optimization - physical therapy, respiratory support
  • Clinical trials - check ClinicalTrials.gov for ongoing studies

Preparing for Exception Requests

Work with your neurologist to document:

  • Unique clinical circumstances
  • Why standard criteria don't apply
  • Expected treatment benefits
  • Risk of delaying therapy

Counterforce Health specializes in helping patients navigate complex prior authorization requirements and can assist with evidence-backed exception requests when standard pathways don't apply.

If Your Request Is Denied

Ohio provides robust appeal options with favorable outcomes for patients who pursue them systematically.

Immediate Steps After Denial

  1. Request detailed denial letter specifying exact reasons
  2. Review Humana's medical policy for Evrysdi coverage criteria
  3. Determine appeal type needed (medical necessity vs. formulary exception)
  4. Note critical deadlines - you have 65 days for Medicare Advantage appeals
Important: Under Humana's August 2024 policy changes, peer-to-peer reviews must be requested BEFORE a denial is issued. Once denied, you must pursue formal appeals.

Appeals Playbook for Ohio

Appeal Level Timeline How to File Required Documents
Internal Appeal (Level 1) 7 days standard, 72 hours expedited Humana member portal or written request Denial letter, additional medical records, physician letter
Internal Appeal (Level 2) 30 days standard, 72 hours expedited Same as Level 1 All previous documents plus any new evidence
External Review (Ohio) 30 days standard, 72 hours expedited Submit to Humana, who forwards to Ohio DOI Complete medical record, external review request form

Ohio External Review Advantage

Ohio's external review process offers significant benefits:

  • No cost to you for independent medical review
  • 180-day deadline to request after final denial (verify with Ohio Department of Insurance)
  • Binding decision on your insurance company
  • Consumer assistance available at 800-686-1526

Common Denial Reasons & Solutions

Denial Reason How to Overturn
Missing genetic confirmation Submit complete SMN1/SMN2 testing results with lab interpretation
Inadequate motor assessment Provide validated assessment tool results (CHOP-INTEND, HFMSE, etc.)
Duplicative therapy concern Document discontinuation of other SMA treatments and medical necessity
Age/weight documentation gaps Submit current measurements and dosing calculations
"Not medically necessary" Provide peer-reviewed literature and treatment guidelines supporting use

Clinician Corner: Medical Necessity Letter Essentials

Include these elements:

  • Specific SMA type and genetic confirmation
  • Baseline motor function with validated assessment scores
  • Treatment goals and expected outcomes
  • Why Evrysdi is appropriate vs. alternatives
  • Monitoring plan and follow-up schedule
  • References to FDA labeling and clinical guidelines

Frequently Asked Questions

How long does Humana prior authorization take in Ohio? Standard requests: 72 hours. Expedited requests: 24 hours. Track your request through Humana's member portal.

What if Evrysdi is non-formulary on my plan? Request a formulary exception with medical necessity documentation. Humana Medicare Advantage plans support non-formulary coverage based on medical necessity.

Can I request an expedited appeal? Yes, if treatment delay would seriously jeopardize your health. Include physician documentation of urgency.

Does step therapy apply to Evrysdi? Verify current requirements in Humana's formulary. Step therapy may require trying other SMA treatments first.

What happens if my external review is denied? You retain rights to seek other remedies including regulatory complaints or legal action, but external review is typically the final administrative step.

How much does Evrysdi cost without coverage? List pricing approaches $340,000 annually (weight-based). Manufacturer support programs may be available - verify current options with your provider.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals through evidence-backed strategies. The platform analyzes denial letters, identifies specific coverage criteria, and drafts targeted rebuttals aligned to each payer's requirements, including complex cases like rare disease medications where standard pathways may not apply.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may change. Always verify current requirements with your insurance provider and consult your healthcare team for medical decisions. For official Ohio insurance assistance, contact the Ohio Department of Insurance at 800-686-1526.

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