By Counterforce Health Team in Evrysdi (risdiplam) —

Getting Evrysdi (Risdiplam) Covered by Cigna in Virginia: Complete Prior Authorization and Appeals Guide

Quick Answer: To get Evrysdi (risdiplam) covered by Cigna in Virginia, you'll need prior authorization with genetic testing confirming SMA (SMN1 mutations), baseline motor function assessment, and specialist involvement. Submit via CoverMyMeds or fax (855) 840-1678. If denied, use Virginia's external review process through the State Corporation Commission within 120 days. Start by gathering genetic test results and contacting your neurologist today.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Approval
  4. Coding and Documentation Requirements
  5. Documentation Packet Checklist
  6. Submission Process
  7. Specialty Pharmacy Routing
  8. After Submission: What to Expect
  9. Common Denial Reasons & Solutions
  10. Appeals Process in Virginia
  11. Cost-Saving Resources
  12. FAQ

Who Should Use This Guide

This guide is for Virginia patients with spinal muscular atrophy (SMA) who need Evrysdi (risdiplam) covered by Cigna, along with their caregivers and healthcare providers. You'll find this most helpful if:

  • Your neurologist has recommended Evrysdi for confirmed SMA
  • You have Cigna commercial insurance or Medicare Advantage in Virginia
  • You're facing a prior authorization requirement or denial
  • You need to understand Virginia's specific appeal rights

Expected outcome: Following this guide increases your chances of approval by ensuring complete documentation and proper submission. If initially denied, Virginia's external review process provides a fair second opinion from independent specialists.

Member & Plan Basics

Coverage Requirements

  • Active Cigna coverage in Virginia (commercial, Medicare Advantage, or employer-sponsored)
  • Specialty drug benefit must be active (Evrysdi requires specialty pharmacy dispensing)
  • Prior authorization is required for all Cigna plans
  • Deductible considerations: High-deductible plans may require meeting deductible first
Note: Self-funded employer plans may have different requirements. Check if your plan participates in Virginia's external review process.

Plan Type Verification

Call Cigna member services at (800) 244-6224 to confirm:

  • Your specialty drug coverage details
  • Prior authorization requirements
  • Preferred specialty pharmacy (typically Accredo)
  • Any step therapy requirements

Clinical Criteria for Approval

Cigna requires strict documentation for Evrysdi approval. Based on their current policy, you must meet these criteria:

Essential Requirements

  1. Confirmed SMA diagnosis with genetic testing showing biallelic SMN1 mutations
  2. Age requirement: Patient must be at least 2 months old
  3. Specialist involvement: Prescribed by or in consultation with a neuromuscular specialist
  4. No concurrent gene therapy: Patient must not have received Zolgensma
  5. Spinraza discontinuation: If switching from Spinraza, it must be discontinued

Clinical Documentation Needed

  • Recent motor function assessment (CHOP INTEND, HFMSE, or similar validated scale)
  • Current weight in kilograms for dosing calculations
  • Documentation of paralysis status and ventilator dependence
  • For females of reproductive age: pregnancy test and contraception counseling
Important: Cigna's August 2025 policy update added a strict requirement that patients who previously received Zolgensma are not eligible for Evrysdi coverage.

Coding and Documentation Requirements

ICD-10 Diagnosis Codes

Use the most specific code available:

  • G12.0: Infantile spinal muscular atrophy, type I (Werdnig-Hoffman)
  • G12.1: Other inherited spinal muscular atrophy (types II and III)
  • G12.9: Spinal muscular atrophy, unspecified (avoid if possible)

NDC and Billing Information

  • NDC (10-digit): 50242-175-07 (oral solution), 50242-202-01 (tablets)
  • NDC (11-digit): 50242-0175-07 (oral solution), 50242-0202-01 (tablets)
  • HCPCS: No permanent J-code assigned; use unclassified codes (J3490, J9999) as directed by Cigna

Documentation Packet Checklist

Required Documents

  • Completed Cigna Evrysdi prior authorization form
  • Genetic testing report confirming SMN1 mutations
  • Recent neurologist consultation notes
  • Baseline motor function assessment
  • Current weight and dosing calculations
  • Treatment history (including any Spinraza or Zolgensma use)
  • Pregnancy test results (if applicable)

Medical Necessity Letter Components

Your neurologist should include:

  1. Patient demographics and confirmed SMA diagnosis
  2. Genetic testing results with specific SMN1 mutations
  3. Current clinical status and motor function scores
  4. Prior treatment history and rationale for Evrysdi
  5. Expected treatment goals and monitoring plan
  6. Specialist qualifications and experience with SMA

Submission Process

How to Submit

  1. Online: CoverMyMeds or SureScripts (preferred method)
  2. Fax: (855) 840-1678
  3. Phone: (800) 882-4462 for urgent requests

Step-by-Step Submission

  1. Gather all documents from the checklist above
  2. Complete the PA form with your neurologist
  3. Submit via preferred method (online portal recommended)
  4. Obtain confirmation number and save all submission records
  5. Follow up within 72 hours if no acknowledgment received
Tip: Submit early in the week (Tuesday-Thursday) for faster processing, as specialty drug reviews may take longer on Mondays and Fridays.

Specialty Pharmacy Routing

Once approved, Evrysdi must be dispensed through Cigna's preferred specialty pharmacy:

Accredo Specialty Pharmacy

  • Phone: (800) 803-2523
  • Process: Cigna will automatically route your prescription
  • Timeline: 3-5 business days for first shipment
  • Delivery: Temperature-controlled shipping to your home

Transfer Steps

  1. Approval notification sent to prescriber and patient
  2. Prescription automatically routed to Accredo
  3. Accredo contacts patient for delivery coordination
  4. First shipment includes dosing supplies and instructions

After Submission: What to Expect

Timeline Expectations

  • Non-urgent requests: Decision within 72 hours
  • Urgent requests: Decision within 24 hours
  • No response: Considered approved if Cigna doesn't respond within regulatory timeframes

Status Checking

  • Online: myCigna app or website
  • Phone: (800) 244-6224 (member services)
  • Provider portal: For healthcare providers

What to Record

  • Confirmation numbers for all submissions
  • Names and dates of phone conversations
  • Copies of all submitted documents
  • Timeline of all communications

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Missing genetic confirmation Submit CLIA-certified genetic test results Lab report showing SMN1 mutations
Incomplete motor assessment Provide validated motor function scores CHOP INTEND, HFMSE, or similar assessment
Prior Zolgensma use Cannot be overturned under current policy N/A - absolute exclusion
Inadequate specialist involvement Letter from neuromuscular specialist Consultation notes and credentials
Dosing documentation gaps Submit current weight and calculations Recent clinic visit with weight measurement

Appeals Process in Virginia

Virginia provides robust appeal rights through the State Corporation Commission Bureau of Insurance.

Internal Appeals with Cigna

  1. First-level appeal: Submit within 180 days of denial
  2. Required documents: Denial letter, additional clinical evidence, appeal letter
  3. Timeline: Cigna has 30 days to respond (expedited: 72 hours for urgent cases)

Virginia External Review Process

If Cigna's internal appeals are unsuccessful:

  1. Eligibility: Must complete Cigna's internal appeal process first
  2. Timeline: Submit within 120 days of final internal denial
  3. Forms: Form 216-A (External Review Request)
  4. Submission: Fax (804) 371-9915 or email [email protected]
  5. Decision: Independent review organization decides within 45 days
  6. Expedited: 72 hours for urgent cases with physician certification

Contact Information

  • Virginia Bureau of Insurance: (877) 310-6560
  • External Review Coordinator: [email protected]
  • Managed Care Ombudsman: Available through same number for additional support
From our advocates: "We've seen many Virginia patients succeed with external review when they include comprehensive genetic testing documentation and a detailed letter from their SMA specialist. The independent reviewers often overturn denials when the medical necessity is clearly established with proper evidence."

Cost-Saving Resources

Manufacturer Support

  • Genentech Patient Foundation: Financial assistance for eligible patients
  • Evrysdi Co-pay Program: May reduce out-of-pocket costs for commercially insured patients
  • Information: Visit Genentech Access Solutions

Additional Resources

  • Virginia Medicaid: May provide coverage if eligible
  • Patient Advocate Foundation: Free case management services
  • National Organization for Rare Disorders (NORD): Grants and resources for rare disease patients

For patients navigating complex insurance denials, Counterforce Health helps turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements.

FAQ

Q: How long does Cigna prior authorization take for Evrysdi in Virginia? A: Non-urgent requests receive decisions within 72 hours. Urgent requests are decided within 24 hours.

Q: What if Evrysdi is not on Cigna's formulary? A: Submit a formulary exception request with medical necessity documentation. Your neurologist must demonstrate why Evrysdi is medically necessary compared to formulary alternatives.

Q: Can I request an expedited appeal in Virginia? A: Yes. If your physician certifies that delays could jeopardize your health, both Cigna internal appeals and Virginia external reviews offer expedited timelines.

Q: Does Virginia's external review cost anything? A: No. Virginia provides external review services at no cost to patients.

Q: What happens if I previously received Zolgensma? A: Under Cigna's current policy, prior Zolgensma treatment disqualifies patients from Evrysdi coverage. This is a strict exclusion that typically cannot be appealed.

Q: How do I find a neuromuscular specialist in Virginia? A: Contact major medical centers like UVA Health or VCU Health, or search the American Association of Neuromuscular & Electrodiagnostic Medicine provider directory.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan terms. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For assistance with insurance appeals and coverage issues, consider consulting with patient advocacy services or Counterforce Health, which specializes in helping patients navigate complex prior authorization and appeal processes.

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