By Counterforce Health Team in Evrysdi (risdiplam) —

How to Get Evrysdi (Risdiplam) Approved by Cigna in Florida: Timeline, Forms & Appeal Guide

Answer Box: Getting Evrysdi Approved by Cigna in Florida

Timeline: Cigna typically responds to Evrysdi prior authorization requests within 5 business days (expedited in 24-72 hours for urgent cases). Requirements: Genetic testing confirming SMA diagnosis, neurologist prescription, baseline motor assessment, and weight-based dosing documentation. First step: Have your neurologist complete Cigna's Evrysdi PA form with all clinical documentation, then submit via CoverMyMeds or Cigna's provider portal for fastest processing.

Table of Contents

  1. What Affects Your Approval Timeline
  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: Florida Appeal Process
  7. Renewal Cycles & Re-Authorization
  8. Timeline Visual & Milestones
  9. Time-Saving Tips

What Affects Your Approval Timeline

Several factors influence how quickly Cigna approves Evrysdi (risdiplam) for spinal muscular atrophy treatment in Florida:

Benefit Type: Evrysdi is typically managed through Cigna's specialty pharmacy benefit via Express Scripts/Accredo, which requires more extensive documentation than standard medications.

Complexity of Criteria: SMA treatments face high scrutiny due to their cost (up to $340,000 annually) and the need for precise genetic confirmation and motor function assessment.

Documentation Completeness: Missing genetic testing results, incomplete motor assessments, or inadequate weight-based dosing calculations are the most common causes of delays.

Note: Florida follows federal standards requiring insurers to respond within 72 hours for routine requests and 24 hours for urgent cases.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Before your neurologist submits the prior authorization, gather these critical documents:

Genetic Testing Results:

  • SMN1 gene testing showing bi-allelic mutations (homozygous deletions or compound heterozygous mutations)
  • SMN2 gene copy number (must be 2-4 copies for symptomatic patients, 2-3 for asymptomatic)
  • Laboratory report confirming 5q SMA diagnosis

Clinical Documentation:

  • Neurologist consultation notes confirming SMA Type I, II, or III diagnosis
  • Baseline motor function assessment using validated scales:
    • MFM-32 for patients aged 2-25+ years
    • RULM for upper limb function assessment
    • BSID-III for infantile-onset cases
  • Current weight and calculated dose (0.2 mg/kg daily)

Treatment History:

  • Documentation of any prior SMA treatments (Spinraza, Zolgensma)
  • Reasons for treatment changes or contraindications
  • Confirmation patient is not on invasive ventilation

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Evrysdi prescriptions Cigna PA Form Cigna Policy
Genetic Testing SMN1/SMN2 confirmation Genetics lab report FDA Label
Specialist Prescription Board-certified neurologist Provider credentials Cigna Requirements
Motor Assessment Baseline functional evaluation Clinical notes with validated scales Medical Literature
Weight Documentation For dose calculation Recent clinic visit Prescribing Information

Submission to Initial Review (1-5 Days)

Florida's Response Time Requirements

Under Florida insurance law, Cigna must respond to prior authorization requests within specific timeframes:

  • Standard requests: 5 business days maximum
  • Urgent requests: 72 hours for life-threatening situations
  • Expedited review: 24 hours when health is at serious risk

What Reviewers Check First

Cigna's initial review focuses on these key criteria:

  1. Genetic confirmation: Valid SMN1/SMN2 testing results
  2. Specialist qualification: Board-certified neurologist prescription
  3. Appropriate diagnosis: ICD-10 codes for SMA (G12.0, G12.1, G12.9)
  4. Treatment history: Documentation of medical necessity
  5. Dosing accuracy: Weight-based calculation verification
Tip: Electronic submission through CoverMyMeds or Cigna's provider portal typically processes faster than fax submissions.

Additional Information Requests (1-7 Days)

If Cigna requests additional information, respond quickly to avoid delays:

Common Information Requests:

  • Updated motor function assessments
  • Additional genetic testing clarification
  • Prior treatment failure documentation
  • Contraindication explanations for alternative therapies

How to Respond Quickly:

  • Use the same submission method (electronic portal preferred)
  • Include the original PA reference number
  • Provide complete documentation in a single submission
  • Mark urgent cases clearly with clinical justification

Counterforce Health's platform can help streamline this process by automatically identifying what additional evidence insurers typically request for SMA treatments and preparing comprehensive responses that address common objections before they arise.

Decision Window & Outcomes

Typical Approval Outcomes

Full Approval: Coverage granted for 12 months with specified quantity limits and pharmacy restrictions (typically specialty pharmacy dispensing required).

Conditional Approval: Coverage approved with additional requirements such as:

  • Periodic motor function monitoring
  • Specialist follow-up requirements
  • Quantity limitations based on weight

Denial: Most common reasons include:

  • Insufficient genetic documentation
  • Missing motor function baseline
  • Lack of specialist prescription
  • Incomplete prior treatment history

Reading Your Approval Letter

Approved requests will specify:

  • Coverage effective dates
  • Authorized quantity per fill
  • Required specialty pharmacy
  • Renewal requirements
  • Any monitoring obligations

If Denied: Florida Appeal Process

Internal Appeal (First Level)

Timeline: You have 180 days from denial notice to file an internal appeal with Cigna.

Process:

  1. Contact Cigna member services at the number on your ID card
  2. Request internal appeal forms or submit online through member portal
  3. Include additional clinical documentation addressing denial reasons
  4. Cigna must respond within 30 days for prospective treatments

External Review (Independent Review)

If Cigna upholds the denial, Florida law provides external review through independent medical experts:

Eligibility: Available after exhausting internal appeals (or if Cigna fails to follow proper procedures)

Timeline: 4 months from final internal denial to request external review

Process: Submit request to Florida Department of Financial Services

Cost: No charge to consumers for external review

Important: External review decisions are binding on insurers under Florida and federal law.

Expedited Appeals

For urgent medical situations, both internal and external reviews can be expedited:

  • Internal expedited: 72 hours
  • External expedited: 72 hours for life-threatening situations

Renewal Cycles & Re-Authorization

When to Re-Authorize

Evrysdi approvals typically require renewal every 12 months. Begin the renewal process 30-45 days before your current authorization expires.

What Speeds Renewals

Continued Medical Necessity: Document ongoing benefit through:

  • Updated motor function assessments showing stability or improvement
  • Specialist notes confirming treatment effectiveness
  • Absence of significant adverse events

Treatment Compliance: Demonstrate adherence through:

  • Pharmacy fill records
  • Regular specialist follow-ups
  • Appropriate dosing adjustments for weight changes

Timeline Visual & Milestones

Phase Timeline Key Actions Expected Outcome
Preparation 0-2 days Gather documentation, complete PA form Ready to submit
Initial Submission Day 1 Electronic submission via portal/CoverMyMeds Acknowledgment received
Under Review Days 2-5 Cigna medical review, possible info requests Preliminary decision
Decision Day 5-7 Approval/denial notification Coverage determination
If Denied Days 8-187 Internal appeal submission and review Appeal decision
External Review Days 188-308 Independent medical review (if needed) Final binding decision

Time-Saving Tips

Portal Usage

  • Register for Cigna's provider portal for real-time status updates
  • Use CoverMyMeds for streamlined electronic PA submission
  • Enable automatic notifications for status changes

Bundled Evidence

Submit comprehensive documentation initially rather than responding to multiple information requests:

  • Complete genetic testing panel results
  • Comprehensive neurologist evaluation
  • Full prior treatment history with outcomes
  • Current weight and dosing calculations

Direct Specialty Routing

  • Ensure prescription routes directly to approved specialty pharmacy
  • Verify pharmacy has current PA approval before dispensing
  • Coordinate between prescriber and pharmacy for seamless fulfillment

From Our Advocates: We've seen cases where families spent months navigating denials for SMA treatments, only to discover that a single missing piece of genetic documentation was holding up approval. The most successful cases we've supported involved neurologists who submitted comprehensive PA packets upfront, including detailed motor function baselines and clear documentation of why Evrysdi was the appropriate choice over alternatives like Spinraza or Zolgensma. This proactive approach often leads to first-time approvals within the standard 5-day window.

Clinician Corner: Medical Necessity Letter Essentials

When supporting an Evrysdi PA or appeal, include these elements in your clinical documentation:

Problem Statement: Clear diagnosis of 5q SMA with genetic confirmation and motor function impact

Prior Treatments: Document any previous SMA therapies, outcomes, and reasons for discontinuation or contraindications

Clinical Rationale: Explain why Evrysdi is medically necessary, referencing:

Monitoring Plan: Outline follow-up schedule for motor assessments and safety monitoring

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Insufficient genetic testing Submit complete SMN1/SMN2 analysis Genetic lab report with copy numbers
Missing motor baseline Provide validated assessment MFM-32, RULM, or BSID-III results
Non-specialist prescriber Transfer to qualified neurologist Board certification verification
Incomplete prior treatment history Document previous therapies Treatment records with outcomes
Dosing concerns Verify weight-based calculation Current weight with dose justification

For complex denials or appeals, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to Cigna's specific policies and Florida's regulatory requirements.

FAQ

How long does Cigna take to approve Evrysdi in Florida? Standard PA requests receive decisions within 5 business days. Expedited requests for urgent medical situations are decided within 24-72 hours under Florida law.

What if Evrysdi is non-formulary on my Cigna plan? You can request a formulary exception through Cigna's standard process. Your neurologist must demonstrate medical necessity and why formulary alternatives are inappropriate.

Can I request an expedited appeal if denied? Yes, if your condition requires urgent treatment. Expedited internal appeals must be decided within 72 hours, and expedited external reviews within 72 hours for life-threatening situations.

Does step therapy apply if I've tried other SMA treatments outside Florida? Treatment history from other states counts toward step therapy requirements. Provide documentation of prior therapies and outcomes regardless of where treatment occurred.

What specialty pharmacies does Cigna use for Evrysdi? Cigna typically requires dispensing through Express Scripts/Accredo specialty pharmacy network. Verify your specific pharmacy options through member services.

How much will I pay for Evrysdi with Cigna coverage? Costs depend on your specific plan's specialty drug tier and copay structure. Check with Cigna about copay assistance programs and manufacturer support options.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical advice. Coverage decisions depend on individual circumstances and plan specifics. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with insurance appeals and coverage challenges, visit Counterforce Health to learn how our platform helps patients and clinicians navigate complex prior authorization requirements.

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