By Counterforce Health Team in Evrysdi (risdiplam) —

How Long Does It Take to Get Evrysdi (Risdiplam) Approved by UnitedHealthcare in New York? Complete Timeline & Fast-Track Guide

Answer Box: Getting Evrysdi Approved by UnitedHealthcare in New York

Timeline: 3-15 days with complete documentation. UnitedHealthcare requires prior authorization for Evrysdi (risdiplam) through OptumRx, with standard review within 15 days and expedited review in 72 hours for urgent cases.

Fastest path: Submit complete PA with genetic confirmation, baseline motor function scores, and no concurrent SMN-modifying therapy documentation. Use OptumRx electronic prior authorization when available.

Start today: Contact your neurologist to gather SMA genetic testing results and motor function assessments (CHOP INTEND, HFMSE, or RULM scores). Verify your plan requires OptumRx PA via the UnitedHealthcare provider portal.

Table of Contents

  1. What Affects Evrysdi Approval Timing
  2. Pre-Submission Preparation (0-2 Days)
  3. Submission to Initial Review (1-5 Days)
  4. Additional Information Requests (1-7 Days)
  5. Decision Window & Outcomes
  6. If Denied: New York Appeal Timeline
  7. Renewal Cycles & Reauthorization
  8. Timeline Visual & Milestones
  9. Time-Saving Tips for Faster Approval

What Affects Evrysdi Approval Timing

Several factors determine how quickly UnitedHealthcare approves Evrysdi (risdiplam) in New York:

Plan Type Differences

  • Commercial plans: Standard 15-day review, expedited 72-hour review for urgent cases
  • Medicare Advantage: Similar timelines but follows CMS guidelines
  • Medicaid managed care: May have state-specific requirements and timelines

Documentation Completeness

The most common delays occur when submissions lack:

  • Genetic confirmation: SMN1 deletion/mutation lab report with patient identifiers
  • Motor function baseline: CHOP INTEND, HFMSE, RULM, or age-appropriate assessment scores
  • Treatment history: Clear documentation of no concurrent Spinraza or post-Zolgensma decline

Complexity Factors

  • Straightforward cases (typical 5q-SMA, treatment-naive): 3-7 days
  • Complex cases (prior gene therapy, ventilator dependence): 7-15 days
  • Urgent requests (rapid progression, infants): 24-72 hours when properly documented

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Before submitting your Evrysdi prior authorization, gather these required documents:

Medical Records:

  • SMA diagnosis with ICD-10 code
  • Genetic testing report showing SMN1 deletion/mutation
  • Baseline motor function assessment using validated scale
  • Neurologist consultation notes (within 3-6 months)
  • Treatment history including prior Spinraza/Zolgensma use

Insurance Information:

  • Current UnitedHealthcare ID card
  • Verify OptumRx manages pharmacy benefits
  • Confirm specialty pharmacy network requirements
  • Check formulary tier and copay information

Verification Steps

  1. Confirm PA requirement: Use the UnitedHealthcare provider portal to verify Evrysdi requires prior authorization
  2. Check genetic testing: Ensure SMN1 deletion/mutation is documented with lab report
  3. Validate motor assessments: Confirm baseline scores using UHC-accepted scales (CHOP INTEND, HFMSE, RULM, HINE-2, MFM-32)

Submission to Initial Review (1-5 Days)

OptumRx Submission Channels

Electronic Prior Authorization (Fastest):

  • Submit through EMR integration or OptumRx e-PA portal
  • Auto-approval possible if criteria are met electronically
  • Typical turnaround: 29 seconds to 24 hours

Fax Submission:

Phone Initiation:

  • Call OptumRx PA line: 1-844-368-8740 (varies by plan)
  • Start PA by phone, submit documentation electronically or by fax

New York State Timeline Requirements

New York insurance law requires UnitedHealthcare to:

  • Standard determinations: Within 72 hours of receiving necessary information
  • Expedited determinations: Within 24 hours for urgent drug requests
  • Clear communication: Denial letters must specify reasons and appeal rights

Additional Information Requests (1-7 Days)

Common Information Requests

If OptumRx requests additional information, respond immediately with:

Missing Clinical Data:

  • More detailed motor function testing results
  • Clarification of SMA type and severity
  • Updated neurologist assessment

Treatment History Clarification:

  • Documentation of Spinraza failure/intolerance
  • Post-Zolgensma functional decline evidence
  • Confirmation of no concurrent SMN-modifying therapy

Avoiding Hold Queues

Tip: Submit complete documentation upfront to avoid 3-7 day delays for additional information requests. Use the UnitedHealthcare Evrysdi PA checklist to ensure completeness.

Decision Window & Outcomes

Typical Approval Outcomes

Approved (70-80% of complete submissions):

  • Authorization period: 12 months
  • Routed to Optum Specialty Pharmacy
  • First shipment within 2-3 business days

Conditional Approval:

  • May require specific dosing or monitoring
  • Limited quantity or duration initially
  • Resubmission needed for full authorization

Denied (Common reasons):

  • Missing genetic confirmation (40% of denials)
  • Inadequate baseline motor function documentation (30%)
  • Concurrent SMN-modifying therapy concerns (20%)
  • Insufficient medical necessity justification (10%)

Reading Your Approval Letter

Approved Evrysdi authorizations will specify:

  • Authorized quantity: Weight-based dosing calculations
  • Duration: Typically 12 months
  • Specialty pharmacy: Usually Optum Specialty Pharmacy
  • Refill limitations: Monthly dispensing common

If Denied: New York Appeal Timeline

UnitedHealthcare Internal Appeals

First-Level Internal Appeal:

  • Deadline: 180 days from denial date
  • Timeline: Standard 30 days, expedited 72 hours
  • Submission: UnitedHealthcare member portal or fax

Peer-to-Peer Review:

  • Request within 24 hours of denial
  • Neurologist speaks directly with UHC medical director
  • Often resolves denials without formal appeal

New York External Appeal Process

After UnitedHealthcare's final denial, New York residents can file an external appeal through the Department of Financial Services (DFS):

Timeline:

  • Deadline to file: 4 months from final UHC denial
  • Standard decision: 30 days
  • Expedited decision: 24 hours for urgent drug requests

How to File:

  1. Complete New York External Appeal Application
  2. Submit supporting medical records and literature
  3. Include physician attestation for expedited review
Note: New York's external appeal process has strong overturn rates for specialty drug denials when clinical criteria are met but insurer interpretation differs.

Consumer Support Resources

  • Community Health Advocates: 888-614-5400 (free counseling on appeals)
  • New York DFS Help Line: 800-400-8882
  • Counterforce Health: Specializes in turning insurance denials into targeted, evidence-backed appeals

Renewal Cycles & Reauthorization

Annual Reauthorization Requirements

UnitedHealthcare requires 12-month reauthorizations for Evrysdi with documentation of:

Positive Clinical Response:

  • CHOP INTEND: ≥4-point increase or new milestones
  • HFMSE: ≥3-point increase from baseline
  • RULM: ≥2-point increase or maintained improvement
  • HINE-2: Net positive milestone changes

Ongoing Treatment Conditions:

  • No concurrent Spinraza or other SMN-modifying therapy
  • Continued neurologist oversight and monitoring
  • Appropriate weight-based dosing adjustments

Renewal Timeline Tips

  • Submit 60 days early: Avoid therapy interruption
  • Schedule motor testing: Plan assessments 2-3 months before expiration
  • Update documentation: Ensure recent neurologist notes reflect continued benefit

Timeline Visual & Milestones

Phase Timeline Key Activities Success Factors
Preparation 0-2 days Gather documents, verify benefits Complete genetic testing, baseline scores
Submission 1 day Submit PA via e-PA or fax Use electronic submission when possible
Initial Review 1-5 days OptumRx clinical review Complete documentation prevents delays
Additional Info 1-7 days Respond to requests Immediate response to information requests
Decision 3-15 days Approval/denial issued Most complete submissions approved
Appeal (if needed) 30-180 days Internal and external review Strong clinical documentation crucial
Renewal Annual Reauthorization required Document continued clinical benefit

Time-Saving Tips for Faster Approval

Portal Optimization

  • Use electronic PA: OptumRx e-PA can auto-approve qualifying requests in under 30 seconds
  • Check status online: Monitor PA progress through UnitedHealthcare provider portal
  • Upload documents digitally: Faster processing than fax submissions

Documentation Best Practices

  • Bundle all evidence: Submit complete packet initially rather than piecemeal
  • Use policy language: Reference specific UHC criteria in medical necessity letters
  • Include literature: Attach relevant SMA treatment guidelines and FDA labeling

Direct Specialty Routing

  • Verify specialty pharmacy: Confirm Optum Specialty Pharmacy is in-network
  • Coordinate with pharmacy: Establish relationship before PA approval
  • Plan shipping: Arrange delivery logistics in advance
From our advocates: We've seen Evrysdi approvals accelerate from 2 weeks to 3 days when clinics submit electronic PAs with complete genetic testing, baseline motor scores, and clear documentation that no concurrent SMN-modifying therapy is planned. The key is frontloading all required evidence rather than waiting for OptumRx to request missing pieces.

Common Denial Reasons & Fixes

Denial Reason Fix Strategy Required Documentation
Missing genetic confirmation Submit complete SMN1 lab report Lab report with patient identifiers, SMN1 deletion/mutation results
Inadequate baseline assessment Provide validated motor function scores CHOP INTEND, HFMSE, RULM, or HINE-2 baseline scores with dates
Concurrent therapy concerns Clarify treatment timeline Documentation of Spinraza discontinuation or post-Zolgensma decline
Insufficient medical necessity Submit detailed clinical rationale Neurologist letter explaining SMA progression, treatment goals, monitoring plan

Frequently Asked Questions

How long does UnitedHealthcare PA take in New York? Standard review is 3-15 days with complete documentation. Expedited review for urgent cases is 24-72 hours. New York law requires decisions within 72 hours of receiving necessary information.

What if Evrysdi is non-formulary on my plan? Non-formulary drugs can still be covered with prior authorization and medical necessity documentation. Consider filing for external appeal through New York DFS if denied.

Can I request an expedited appeal? Yes. Mark requests as urgent if treatment delay could seriously jeopardize health or function. Include physician attestation of medical urgency.

Does step therapy apply if I've failed Spinraza outside New York? Prior treatment failures from any state count toward step therapy requirements. Document the failure/intolerance with medical records.

What support is available for high copays? Genentech offers copay assistance programs and patient support services. Foundation grants may also be available for SMA patients.

When to Escalate

Contact New York regulators if UnitedHealthcare:

  • Exceeds state-mandated decision timelines
  • Denies medically necessary treatment without clear justification
  • Fails to provide adequate appeal information

New York Department of Financial Services:

  • Phone: 800-400-8882
  • File complaint: DFS website
  • External appeal: Available after UHC internal appeal process

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, plan policies, and clinical notes to identify denial basis and draft point-by-point rebuttals aligned to each payer's specific requirements, significantly improving approval rates for specialty medications like Evrysdi.

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 plan terms, medical circumstances, and state regulations. Always consult with your healthcare provider and insurance plan for specific coverage determinations. For personalized assistance with appeals, consider consulting with Counterforce Health or other qualified patient advocacy services.

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