By Counterforce Health Team in Evrysdi (risdiplam) —

Get Evrysdi (Risdiplam) Covered by Cigna in Ohio: Complete Forms, Appeals & Timeline Guide

Answer Box: Getting Evrysdi (Risdiplam) Covered by Cigna in Ohio

Fastest path to approval: Submit prior authorization through CoverMyMeds portal with genetic confirmation of 5q SMA, baseline motor assessment, and specialist prescription. If denied, you have 180 days for internal appeal, then 60 days for Ohio external review through the Department of Insurance (1-800-686-1526). Most denials stem from missing genetic testing or incomplete motor function documentation.

Start today: Contact your neurologist to ensure they have your SMN1 gene test results and current motor function scores before submitting the PA request.

Table of Contents

Verify Your Cigna Plan & Find Current Forms

Before starting your Evrysdi (risdiplam) prior authorization, confirm your specific Cigna plan type. Commercial, Medicare Advantage, and Medicaid managed care plans have different forms and processes.

Check your plan:

  1. Look at your Cigna member ID card for plan type
  2. Log into MyCigna portal to view your prescription drug formulary
  3. Call the member services number on your card to confirm specialty drug coverage
Note: Most Cigna plans route specialty medications like Evrysdi through Express Scripts specialty pharmacy network.

Prior Authorization Forms & Requirements

Current Evrysdi PA Form (2024)

Cigna requires a specific prior authorization form for Evrysdi that includes:

  • Patient demographics and insurance information
  • Prescribing physician details (must be neurologist or specialist)
  • SMA diagnosis confirmation with ICD-10 codes
  • Genetic testing results showing SMN1 gene deletion/mutation
  • Baseline motor function assessment scores
  • Previous SMA therapy history (if applicable)
  • Weight-based dosing calculation

Download the form: Access the current Cigna Evrysdi PA form through their prescription drug authorization forms page or request it via your provider's EHR system.

Medical Necessity Criteria

Your physician must document:

  • Genetic confirmation: Laboratory results showing biallelic SMN1 gene deletion or mutation
  • Motor assessment: Baseline scores using validated scales (HINE-2, CHOP-INTEND, HFMSE, or RULM depending on age)
  • SMA type and SMN2 copy number: Critical for dosing and prognosis
  • Specialist involvement: Prescription from or consultation with neuromuscular specialist

Submission Portals & Electronic Options

Primary Electronic Submission

CoverMyMeds (Recommended):

Alternative Electronic Options:

  • SureScripts integration through your provider's EHR
  • Cigna provider portal (requires account setup)

Required Documentation Upload

When submitting electronically, attach:

  • Genetic testing report (SMN1 deletion/mutation)
  • Motor function assessment scores
  • Recent clinic notes from neuromuscular specialist
  • Previous therapy history (if applicable)
  • Insurance card copy

Fax Numbers & Mailing Addresses

Cigna PA Fax Numbers

  • General Prior Authorization: Use number listed on current PA form
  • Expedited/Urgent Requests: Call 1-800-882-4462 for verbal submission

Mailing Address for PA Documents

Cigna Healthcare
Prior Authorization Department
[Address varies by plan - check current form]
Tip: Always include a cover sheet with patient name, date of birth, member ID, and "EVRYSDI PRIOR AUTHORIZATION" clearly marked.

Specialty Pharmacy Setup

Once Cigna approves your Evrysdi PA, the medication will be dispensed through their specialty pharmacy network, typically Express Scripts/Accredo.

Onboarding Steps

  1. Automatic enrollment: Cigna will transfer your prescription to their preferred specialty pharmacy
  2. Patient intake call: Expect a call within 24-48 hours to verify shipping address and insurance
  3. Clinical consultation: Pharmacist will review dosing, storage, and administration instructions
  4. Delivery setup: Monthly shipments with temperature monitoring

Transfer Instructions

If you need to transfer from another specialty pharmacy:

  • Contact Express Scripts at 1-800-753-2851
  • Provide current pharmacy contact information
  • Request expedited transfer to avoid therapy gaps

Member & Provider Support Lines

Cigna Member Services

  • Primary number: 1-800-244-6224
  • 24/7 customer service: 1-800-997-1654
  • Plan-specific support: Number on back of your ID card

Provider Support

  • Prior authorization line: 1-800-882-4462
  • Pharmacy benefits: Express Scripts provider line

What to Ask When Calling

  • "What's the status of my Evrysdi prior authorization?"
  • "Can you expedite this request due to medical urgency?"
  • "What additional documentation do you need?"
  • "Is there a peer-to-peer review option available?"

Ohio Insurance Appeals & External Review

Internal Appeals with Cigna

If your Evrysdi PA is denied, you have 180 days from the denial date to file an internal appeal.

Submit appeals to:

Cigna Healthcare
Attn: Appeals
PO Box 188081
Chattanooga, TN 37422

Required documents:

  • Copy of denial letter
  • Medical records supporting medical necessity
  • Updated motor function assessments
  • Physician letter explaining clinical rationale

Ohio External Review Process

After exhausting Cigna's internal appeals, you can request external review through the Ohio Department of Insurance within 60 days of the final denial.

Ohio Department of Insurance Contact:

External review benefits:

  • Independent medical expert review
  • Free for consumers (insurer pays fees)
  • Binding decision on Cigna if approved
  • 30-day standard review (72 hours if expedited)

Common Denial Reasons & Solutions

Denial Reason How to Overturn
Missing genetic testing Submit SMN1 gene test results showing deletion/mutation
Incomplete motor assessment Provide baseline scores using validated SMA scales
Non-specialist prescriber Get prescription from neurologist or obtain specialist consultation
Step therapy required Document failure/intolerance to required first-line therapies
Quantity limit exceeded Justify weight-based dosing with clinical rationale
"Not medically necessary" Submit comprehensive medical necessity letter with guidelines

Medical Necessity Documentation

Clinician Corner: Essential Documentation

Medical Necessity Letter Checklist:

  • Problem statement: Progressive muscle weakness characteristic of SMA
  • Genetic confirmation: SMN1 biallelic deletion/mutation with SMN2 copy number
  • Functional assessment: Baseline motor scores and current capabilities
  • Treatment history: Previous therapies tried, outcomes, and reasons for discontinuation
  • Clinical rationale: Why Evrysdi is appropriate for this patient's SMA type and stage
  • Monitoring plan: How motor function and safety will be assessed

Key Guidelines to Reference:

From our advocates: We've seen the strongest approvals when neurologists include specific motor milestone data (like "patient lost ability to sit independently at age 18 months") rather than general statements about muscle weakness. This concrete functional data helps medical reviewers understand the progression and need for intervention.

FAQ: Cigna Coverage for Evrysdi in Ohio

How long does Cigna prior authorization take for Evrysdi? Standard review takes 5-7 business days via electronic submission, up to 14 days by fax. Expedited reviews for urgent cases are completed within 24-72 hours.

What if Evrysdi is non-formulary on my Cigna plan? You can request a formulary exception with clinical justification. Your doctor must demonstrate medical necessity and why formulary alternatives aren't appropriate.

Can I get an expedited appeal in Ohio? Yes, if delay would seriously jeopardize your health. Your physician must certify medical urgency, and Cigna must respond within 72 hours for medical appeals.

Does step therapy apply to Evrysdi? Some Cigna plans require trying other SMA treatments first. You can request a step therapy override if you've already failed required medications or they're contraindicated.

What's the cost of Evrysdi with Cigna coverage? Costs vary by plan, but specialty tier copays typically range from $150-500 per month. Check with Genentech's patient support program for copay assistance.

How do I transfer Evrysdi prescriptions between states? Contact your new state's Cigna member services and specialty pharmacy to update your address and ensure continued coverage under your plan's network.

At Counterforce Health, we help patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create compelling appeals that align with payer requirements and clinical evidence. If you're facing a complex Evrysdi denial, Counterforce Health can help identify the specific denial basis and draft a point-by-point rebuttal using the right clinical documentation and peer-reviewed evidence.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and medical circumstances. Always consult with your healthcare provider and insurance plan directly for specific coverage questions. For additional assistance with health insurance appeals in Ohio, contact the Ohio Department of Insurance consumer services division.

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