By Counterforce Health Team in Evrysdi (risdiplam) —

How Long Does It Take to Get Evrysdi (Risdiplam) Approved by Aetna in Virginia? Complete Timeline and Appeal Guide

Answer Box: Getting Evrysdi Approved by Aetna in Virginia

Aetna typically takes 15-30 days to approve Evrysdi (risdiplam) for SMA patients, or 72 hours for expedited reviews. You'll need genetic confirmation of biallelic SMN1 mutations, clinical SMA diagnosis from a neurologist, and documentation of prior therapy attempts. If denied, you have 180 days to appeal internally and 120 days to request external review through Virginia's State Corporation Commission. Start today: Contact your neurologist to gather genetic test results and motor function assessments, then submit via CVS Caremark's specialty prior authorization portal.

Table of Contents

What Affects Evrysdi Approval Timing

Several factors determine how quickly Aetna approves your Evrysdi prior authorization in Virginia:

Benefit Type Impact:

  • Commercial plans: Standard 15-30 day review through CVS Caremark
  • Medicare Advantage: Similar timeline but may have additional CMS requirements
  • Medicaid managed care: Often faster due to state oversight requirements

Documentation Completeness: The single biggest factor affecting approval speed is having complete documentation upfront. Aetna's medical reviewers look for:

  • Genetic confirmation of biallelic SMN1 mutations
  • Clinical diagnosis from a neurologist or pediatric neurologist
  • Baseline motor function assessments (CHOP INTEND, Hammersmith scales)
  • Prior therapy history and response documentation

Complexity Factors:

  • First-time SMA treatment requests: May require additional clinical review
  • Patients switching from Spinraza or Zolgensma: Need documentation of prior response
  • Off-label dosing requests: Trigger medical director review
Note: Virginia law requires insurers to make coverage decisions within specific timeframes, which helps ensure Aetna adheres to posted timelines.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist:

  • Genetic test results: CLIA-certified lab report showing biallelic SMN1 deletion/mutation
  • Clinical diagnosis: Neurologist notes specifying SMA type (1, 2, or 3)
  • Motor function scores: Baseline assessments using validated scales
  • Insurance information: Member ID, group number, plan details
  • Prior authorization form: Aetna's Evrysdi-specific PA form
  • Prescriber information: NPI number, DEA, clinic contact details

Verification Steps:

  1. Confirm formulary status: Check if Evrysdi is on your specific plan's formulary
  2. Review step therapy requirements: Document any prior SMA treatments attempted
  3. Verify benefit type: Medical vs. pharmacy benefit affects submission routing

ICD-10 Coding:

  • G12.0 (Infantile spinal muscular atrophy, type I)
  • G12.1 (Other inherited spinal muscular atrophy)
  • G12.9 (Spinal muscular atrophy, unspecified)
Tip: Start gathering documents 1-2 weeks before your appointment. Genetic testing and motor assessments can take time to obtain from previous providers.

Submission to Initial Review (1-5 Days)

Submission Methods:

  1. CVS Caremark ePA Portal (fastest): Electronic submission with real-time status updates
  2. Fax: Check current fax number on your PA form
  3. Phone: CVS Caremark Specialty PA line at 1-866-814-5506

What Reviewers Check First:

  • Eligibility verification: Active member status and benefit coverage
  • Clinical criteria match: Does diagnosis align with FDA-approved indications?
  • Form completeness: All required fields filled, signatures present
  • Supporting documentation: Genetic tests and clinical notes attached

Virginia-Specific Requirements: Virginia law requires insurers to acknowledge PA receipt within 1 business day and provide estimated decision timelines. You should receive confirmation of submission within 24-48 hours.

Routing Process:

  • Specialty medications like Evrysdi typically route to CVS Caremark's specialty review team
  • Complex cases may escalate to Aetna's medical director for final decision
  • Expedited requests bypass standard queues with physician urgency certification

Additional Information Requests (1-7 Days)

Common Information Requests:

  • Missing genetic confirmation: Lab reports must show specific SMN1 mutations
  • Incomplete motor assessments: Reviewers need baseline functional scores
  • Prior therapy documentation: Evidence of previous treatments tried/failed
  • Dosing clarification: Weight-based calculations must match FDA labeling

How to Respond Quickly:

  • Check your provider portal daily for status updates
  • Respond to requests within 24-48 hours to avoid delays
  • Submit additional documents via the same method as original submission
  • Include your PA reference number on all correspondence

Hold Queue Management: If your case is placed on hold, contact CVS Caremark directly to understand specific requirements. Don't wait for written requests—proactive follow-up can reduce processing time by several days.

Decision Window & Outcomes

Standard Timeline:

  • Routine decisions: 15-30 days from complete submission
  • Expedited decisions: 72 hours with physician urgency certification
  • Complex cases: May extend to 45 days with member notification

Approval Outcomes:

  • Full approval: Coverage authorized for prescribed duration
  • Partial approval: May include quantity limits or dosing restrictions
  • Conditional approval: Coverage pending additional monitoring requirements

Reading Your Approval Letter:

  • Authorization number: Required for pharmacy claims processing
  • Coverage period: Typically 12 months for Evrysdi
  • Quantity limits: Monthly supply restrictions if applicable
  • Pharmacy restrictions: May require CVS Specialty Pharmacy
Important: Save your approval letter—you'll need it for prescription fills and annual renewals.

If Denied: Virginia Appeal Process

Internal Appeal Timeline:

  • Filing deadline: 180 days from denial notice
  • Standard appeal decision: 30 days
  • Expedited appeal: 72 hours for urgent cases
  • Required documentation: Denial letter, additional clinical evidence, prescriber attestation

Appeal Preparation:

  1. Review denial reason: Common issues include incomplete documentation or step therapy requirements
  2. Gather additional evidence: Peer-reviewed studies, clinical guidelines, specialist letters
  3. Request peer-to-peer review: Your neurologist can speak directly with Aetna's medical director
  4. Submit via multiple channels: Portal, fax, and certified mail for important appeals

Strengthening Your Appeal:

  • Include FDA labeling supporting Evrysdi's indication for your SMA type
  • Reference clinical guidelines from organizations like Cure SMA or AAN
  • Document functional decline without treatment or improvement with Evrysdi
  • Provide comparative analysis if step therapy is an issue

Annual Renewal Cycles

Renewal Frequency: Aetna requires annual prior authorization renewal for Evrysdi, typically 12 months from initial approval date.

Ongoing Coverage Requirements:

  • Continued diagnosis: Updated clinical notes confirming SMA status
  • Treatment response: Documentation of clinical benefit or stabilization
  • Motor function updates: Annual assessments showing maintained or improved function
  • Adherence confirmation: Pharmacy records showing consistent medication pickup

Renewal Preparation Timeline:

  • 90 days before expiration: Schedule neurology appointment
  • 60 days before: Submit renewal PA with updated documentation
  • 30 days before: Follow up on pending renewal decisions

What Speeds Renewals:

  • Consistent pharmacy records showing good adherence
  • Stable or improved motor function scores
  • No safety concerns or adverse events
  • Same prescriber and dosing regimen

Timeline Visual & Milestones

Milestone Timeframe Key Actions Expected Outcome
Pre-submission 0-2 days Gather documents, verify coverage Complete PA packet ready
Submission Day 1 Submit via ePA portal or fax Acknowledgment within 24-48 hours
Initial review Days 1-5 Eligibility and completeness check Request for additional info or approval
Medical review Days 5-15 Clinical criteria assessment Preliminary decision
Final decision Days 15-30 Medical director sign-off if needed Approval or denial letter
Appeal (if needed) Days 31-210 Internal appeal process Overturned denial or external review
External review Days 211-255 Virginia SCC independent review Final binding decision

Time-Saving Tips for Faster Approval

Portal Optimization:

  • Use CVS Caremark's electronic prior authorization system when available
  • Set up automated status notifications
  • Upload all documents in a single submission to avoid back-and-forth

Documentation Bundling:

  • Create a comprehensive "Evrysdi packet" with all required documents
  • Include a cover letter summarizing your case and highlighting key evidence
  • Organize documents chronologically with clear labels

Specialty Pharmacy Coordination:

  • Work with CVS Specialty Pharmacy's patient advocates
  • They can help navigate PA requirements and follow up on pending decisions
  • Specialty pharmacies often have direct lines to PA review teams

Provider Communication:

  • Ensure your neurologist's office has experience with SMA medication PAs
  • Request they include specific language about medical necessity in their notes
  • Ask for peer-to-peer review if initial PA is denied
From our advocates: "We've seen the fastest approvals when patients work with their specialty pharmacy from day one. They know exactly what Aetna needs and can often get decisions within the minimum timeframe. One family got their approval in just 12 days by having everything perfectly organized upfront."

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Missing genetic confirmation Submit CLIA lab report Genetic test showing biallelic SMN1 mutations
Step therapy not met Document prior failures Records of Spinraza trials or contraindications
Incomplete diagnosis Neurologist evaluation Clinical notes specifying SMA type and severity
Dosing concerns Provide weight calculations Current weight and FDA dosing guidelines
"Experimental" designation Reference FDA approval FDA label and indication-specific studies
Non-formulary status Request formulary exception Medical necessity letter with alternatives tried

Virginia External Review Rights

If Aetna denies your internal appeal, Virginia provides robust external review rights through the State Corporation Commission (SCC).

Eligibility Requirements:

  • Must complete Aetna's internal appeal process first
  • Denial must be based on medical necessity or experimental treatment determination
  • Must be a Virginia-issued plan or participating self-funded plan

Filing Process:

Decision Timeline:

  • Standard review: 45 days
  • Expedited review: 72 hours for urgent cases
  • Decision binding: On both you and Aetna

What to Include:

  • Complete medical records supporting Evrysdi necessity
  • All correspondence with Aetna
  • Independent medical opinions if available
  • Comparative analysis of treatment options

The external review process in Virginia has helped many patients access specialty medications that were initially denied. Independent medical reviewers often have different perspectives than insurance company physicians.

For patients seeking assistance with complex appeals, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform helps identify specific denial reasons and drafts point-by-point rebuttals aligned to each plan's requirements, pulling the right clinical evidence and citations to support medical necessity arguments.

FAQ

How long does Aetna take to approve Evrysdi in Virginia? Standard approvals take 15-30 days, while expedited requests are decided within 72 hours with physician certification of urgency. Complete documentation upfront significantly speeds the process.

What if Evrysdi is non-formulary on my Aetna plan? You can request a formulary exception by demonstrating medical necessity and documenting that formulary alternatives are inappropriate or ineffective for your specific case.

Can I request an expedited appeal if Aetna denies Evrysdi? Yes, if your physician certifies that waiting for a standard appeal could jeopardize your health, Aetna must decide expedited appeals within 72 hours.

Does step therapy apply if I failed previous treatments outside Virginia? Previous treatment failures from other states count toward step therapy requirements, but you must provide documentation from those providers showing inadequate response or intolerance.

What happens if I miss the appeal deadline? If you miss Aetna's 180-day internal appeal deadline, you may still be able to file directly for external review with Virginia's SCC within their 120-day window, depending on circumstances.

How often do I need to renew prior authorization for Evrysdi? Aetna typically requires annual renewal with updated clinical documentation showing continued medical necessity and treatment response.

Can Virginia's external review overturn Aetna's denial? Yes, Virginia's independent review organizations have overturned many specialty drug denials when medical necessity is clearly demonstrated. Their decisions are binding on Aetna.

What if my employer plan is self-funded? Many Virginia-based self-funded plans opt into the state's external review process. If not, you may have federal external review rights through HHS. The Virginia SCC can help determine your options.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes may vary by plan and can change. Always verify current requirements with Aetna member services and consult with your healthcare provider about treatment decisions. For personalized assistance with prior authorization and appeals, consider working with experienced patient advocates who understand insurance processes and can help present your case effectively.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.