By Counterforce Health Team in Evrysdi (risdiplam) —

Getting Evrysdi (Risdiplam) Covered by Aetna CVS Health in Washington: Prior Authorization, Appeals, and Cost Strategies

Answer Box: Fast Track to Evrysdi Coverage

To get Evrysdi (risdiplam) covered by Aetna CVS Health in Washington: Your doctor must submit a prior authorization with genetic testing confirmation, weight-based dosing calculations, and documentation of spinal muscular atrophy diagnosis. Evrysdi requires specialty pharmacy dispensing through CVS Specialty. If denied, you have 60 days for internal appeals, then 180 days for Washington's external review process. Commercial insurance patients may qualify for Genentech's copay assistance program. Start by having your provider complete Aetna's Medical Exception/Prior Authorization form today.

Table of Contents

  1. Understanding Evrysdi Coverage Requirements
  2. Prior Authorization Process
  3. Common Denial Reasons and Solutions
  4. Appeals Process in Washington
  5. Specialty Pharmacy Coordination
  6. Cost Management Strategies
  7. When to Escalate
  8. FAQ

Understanding Evrysdi Coverage Requirements

Aetna CVS Health classifies Evrysdi (risdiplam) as a Tier 4 specialty medication requiring prior authorization and dispensing through CVS Specialty Pharmacy. The medication treats spinal muscular atrophy (SMA) in pediatric and adult patients, with weight-based dosing administered orally at home.

Coverage at a Glance

Requirement Details Where to Find
Prior Authorization Required Aetna formulary documents
Specialty Pharmacy CVS Specialty only Plan drug guide
Tier Level Tier 4 (highest copay) Member portal
Age Restrictions None (FDA-approved for all ages) FDA labeling
Diagnosis Codes G12.0, G12.1, G12.9 (SMA types) Provider documentation
Appeal Deadline 60 days (internal), 180 days (external) Washington OIC guidelines
Note: Evrysdi must be dispensed as a constituted liquid solution, never as powder. The specialty pharmacy handles this preparation and ships directly to patients.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Genetic Testing Confirmation (Provider)
    • Submit SMN1 gene deletion/mutation documentation
    • Include SMN2 copy number if available
    • Timeline: Results typically available within 1-2 weeks
  2. Clinical Documentation (Provider)
  3. Prior Therapy Documentation (Provider)
    • List any previous SMA treatments (Spinraza, Zolgensma)
    • Document outcomes, tolerability, or contraindications
    • Include rationale for Evrysdi selection
  4. Submission (Provider)
    • Fax completed forms to number on authorization form
    • Call provider services for urgent cases
    • Online portal submission available
  5. Follow-Up (Patient/Provider)
    • Track authorization status through provider portal
    • Contact CVS Specialty for pharmacy coordination
    • Prepare for potential peer-to-peer review

Clinician Corner: Medical Necessity Documentation

Your medical necessity letter should include:

  • Diagnosis: Confirmed SMA with genetic testing results
  • Clinical Presentation: Current motor function, age at onset, SMA type
  • Treatment History: Previous therapies tried, outcomes, intolerances
  • Rationale: Why Evrysdi is appropriate (oral administration, home use, age considerations)
  • Monitoring Plan: How treatment response will be assessed
  • Dosing Justification: Weight-based calculations per FDA labeling

Common Denial Reasons and Solutions

Denial Reason Solution Documentation Needed
Missing genetic confirmation Resubmit with SMN1 testing Lab reports showing gene deletion/mutation
Inadequate prior therapy documentation Document treatment history Previous authorization records, provider notes
Dosing concerns Provide weight-based calculations Current weight, FDA dosing chart
"Experimental" designation Challenge with FDA approval FDA approval letter, clinical guidelines
Step therapy requirement Request override Medical contraindications to alternatives
Tip: If Aetna requests a peer-to-peer review, have your neurologist prepared with recent clinical data and treatment rationale. These calls often resolve authorization delays.

Appeals Process in Washington

Washington state provides robust consumer protections for insurance denials, with multiple levels of review available.

Internal Appeals (First Step)

  • Timeline: 60 days from denial date to file
  • Process: Submit written appeal to Aetna member services
  • Decision: Within 30-60 days (expedited: 72 hours if urgent)
  • Required: Copy of denial letter, additional medical records, provider support

External Review (Independent Review Organization)

If internal appeals fail, Washington residents can request external review through the Office of the Insurance Commissioner.

  • Timeline: 180 days from final internal denial
  • Process: Submit request to Washington OIC
  • Decision: 15 days standard, 72 hours expedited
  • Cost: Free to consumers
  • Binding: Decision is final and binding on Aetna

Appeals Playbook for Washington

  1. Internal Appeal - Submit to Aetna within 60 days
  2. Gather Evidence - Medical records, provider letters, clinical guidelines
  3. External Review - File with Washington OIC within 180 days
  4. IRO Assignment - Independent medical experts review case
  5. Final Decision - Binding determination within 15 days
Important: Keep detailed records of all communications and submit appeals via certified mail or trackable methods.

Specialty Pharmacy Coordination

CVS Specialty Pharmacy coordinates Evrysdi dispensing for Aetna members through a specialized process designed for complex medications.

What to Expect

  • Proactive Outreach: CVS Specialty will contact you after authorization
  • Benefits Verification: Confirmation of coverage and copay calculations
  • Delivery Coordination: Direct-to-home shipping with temperature control
  • Ongoing Support: Refill coordination and adherence monitoring

Key Coordination Points

  • Evrysdi is dispensed as constituted liquid (never powder)
  • Refrigeration required (2°C to 8°C)
  • 64-day expiration after constitution
  • Weight-based dosing requires periodic recalculation

Counterforce Health helps patients navigate these complex specialty pharmacy requirements, ensuring proper documentation and coordination between providers, insurers, and pharmacies for optimal treatment access.

Cost Management Strategies

Understanding Your Costs

Evrysdi typically falls on Tier 4 (specialty tier) with the highest cost-sharing requirements. Annual costs can reach $340,000 at list price, making cost assistance crucial.

Financial Assistance Options

For Commercial Insurance:

  • Genentech Copay Program: May reduce out-of-pocket costs for eligible patients
  • Eligibility: Commercial insurance required (not government programs)
  • Contact: 833-387-9734 or EvrysdiCopay.com

For All Patients:

  • Genentech Patient Foundation: Free medication for qualifying uninsured/underinsured patients
  • Income-Based: Financial need assessment required
  • Application: Gene.com Patient Foundation

Formulary Exception Strategies

If facing high copays, request a tiering exception to move Evrysdi to a lower cost tier:

  • Document lack of effective formulary alternatives
  • Provide medical necessity for Evrysdi specifically
  • Submit provider attestation of clinical appropriateness
  • Follow Aetna's formulary exception process

When to Escalate

Contact the Washington State Office of the Insurance Commissioner if:

  • Aetna fails to meet decision deadlines
  • You suspect improper denial practices
  • You need help navigating the appeals process

Contact Information:

  • Phone: 1-800-562-6900
  • Website: insurance.wa.gov
  • Consumer Advocacy team available for guidance

The OIC can provide template appeal letters and guide you through Washington's external review process.

FAQ

How long does Aetna CVS Health prior authorization take for Evrysdi in Washington? Standard decisions within 72 hours of receiving complete documentation. Expedited reviews (when medically urgent) within 24 hours.

What if Evrysdi is non-formulary on my Aetna plan? Request a formulary exception through your provider. Include medical necessity documentation and evidence that formulary alternatives are inappropriate.

Can I get expedited appeals in Washington? Yes, if your provider certifies that waiting could seriously harm your health. Expedited external reviews receive decisions within 72 hours.

Does step therapy apply if I've tried treatments outside Washington? Yes, document all previous SMA treatments regardless of where received. Out-of-state treatment records are valid for step therapy requirements.

What happens if CVS Specialty can't fill my Evrysdi prescription? Contact Aetna member services immediately. They may approve temporary fills at other specialty pharmacies or coordinate with the manufacturer.

How do I continue Evrysdi during an appeal? Notify Aetna within 10 days of denial to continue coverage during appeal. You may be responsible for costs if the appeal is unsuccessful.

From our advocates: We've seen families successfully overturn Evrysdi denials by ensuring genetic testing documentation was complete and working closely with their neurologist to provide detailed treatment rationales. The key is thorough documentation and persistence through the appeals process.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeals processes, ensuring families get access to critical medications like Evrysdi when they need them most.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual circumstances and plan details. Always consult with your healthcare provider and insurance representative for personalized guidance. For assistance with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900.

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