By Counterforce Health Team in Evrysdi (risdiplam) —

How to Get Evrysdi (risdiplam) Covered by Aetna (CVS Health) in California: Prior Authorization, Appeals, and State Protections

Answer Box: Getting Evrysdi Covered in California

Getting Evrysdi (risdiplam) covered by Aetna (CVS Health) in California requires prior authorization with genetic confirmation of SMA, baseline motor assessments, and specialist prescription. If denied, California's robust appeal protections give you strong reversal odds—about 68% of specialty drug appeals succeed through Independent Medical Review (IMR).

Your fastest path:

  1. Submit PA with genetic test results showing SMN1 deletion/mutation
  2. Include baseline motor function scores and specialist letter
  3. If denied, file internal appeal within 180 days, then IMR within 6 months

Start today: Contact your neurologist to gather genetic test results and motor assessments for the PA submission.

Table of Contents

Why California State Rules Matter

California's health insurance regulations are among the most consumer-friendly in the nation, providing significant protections for patients needing specialty medications like Evrysdi. The state operates under two regulatory systems: the Department of Managed Health Care (DMHC) oversees most HMOs and managed care plans, while the California Department of Insurance handles other policies.

Key advantages for Evrysdi patients:

  • No-cost appeals process - You pay nothing for Independent Medical Review
  • High success rates - 68% of specialty drug IMRs are approved statewide
  • Strong step therapy protections under AB 347 (2021)
  • Binding external review decisions that insurers must follow
  • Expedited timelines for urgent cases (72 hours or less)

These state protections work alongside Aetna's plan policies, often providing additional pathways when initial coverage requests are denied.

Prior Authorization Requirements

Aetna (CVS Health) requires comprehensive documentation for Evrysdi coverage. Based on their current PA criteria, you'll need:

Coverage at a Glance

Requirement What It Means Where to Find It
Genetic confirmation SMN1 gene deletion/mutation test results Genetics lab report from CLIA-certified facility
Specialist prescription Neurologist or SMA specialist must prescribe Provider's medical license verification
Baseline motor assessment CHOP INTEND, HINE-2, or HFMSE scores Physical therapy or neurology evaluation
Treatment history Documentation of prior SMA therapies tried Medical records showing Spinraza/Zolgensma use
Weight-based dosing Current weight for proper dosing calculation Recent clinic visit documentation

Step-by-Step: Fastest Path to Approval

  1. Gather genetic documentation (Patient/Family): Obtain official lab report showing biallelic SMN1 mutations from your genetics provider
  2. Schedule baseline assessment (Clinic): Complete motor function evaluation using validated SMA scales
  3. Submit PA request (Provider): Use Aetna's PA portal with complete documentation package
  4. Track submission (Patient): Follow up within 5-7 business days if no response received
  5. Prepare for CVS Specialty (Patient): Once approved, coordinate with CVS Specialty Pharmacy for dispensing
  6. Monitor approval timeline (All): Standard review takes 15-30 days; expedited available for urgent cases
  7. Appeal if denied (All): File internal appeal within 180 days, then escalate to DMHC if needed

Turnaround Standards and Timelines

California law sets strict response requirements that often exceed Aetna's standard timelines:

Standard vs. Expedited Review

Standard Prior Authorization:

  • Aetna timeline: 15-30 days for specialty medications
  • California requirement: Plans must respond within regulatory timeframes or approval is automatic
  • Renewal: Annual review required with updated clinical documentation

Expedited/Urgent Review:

  • When available: Life-threatening conditions or significant health deterioration risk
  • Timeline: 72 hours maximum (often 24-48 hours)
  • Trigger: Provider attestation of medical urgency
Tip: If your neurologist documents that delayed Evrysdi access could worsen motor function decline, request expedited review to bypass standard waiting periods.

Step Therapy Protections

California's AB 347 provides strong step therapy override protections, particularly relevant since some Aetna plans may require trying Spinraza or Zolgensma first.

Medical Exception Criteria

Your provider can request a step therapy exception if:

  • Prior drug is contraindicated - Patient has allergies or medical conditions preventing use
  • Previous failure documented - Already tried and failed the preferred therapy under current or past coverage
  • Patient stability risk - Currently stable on Evrysdi; switching poses clinical risk
  • Clinical inappropriateness - Provider determines preferred drug isn't in patient's best interest

Documentation That Helps

When requesting step therapy exceptions, include phrases like:

  • "Patient has documented intolerance to intrathecal procedures required for Spinraza"
  • "Previous Spinraza treatment resulted in insufficient motor improvement after 6 months"
  • "Oral administration of Evrysdi is medically necessary due to patient's clinical condition"

The DMHC guidance on AB 347 requires plans to approve exceptions meeting these criteria within standard PA timeframes.

Continuity of Care Rights

California protects patients transitioning between plans or when formularies change:

Transition Coverage:

  • New plan enrollment: Up to 30 days of temporary coverage while PA processes
  • Formulary changes: Plans must provide advance notice and transition options
  • Mid-year switches: Existing therapy continuation rights during benefit year

Ongoing Therapy Protection:

  • If you're stable on Evrysdi and your plan changes coverage mid-year, you may qualify for continued coverage
  • Document clinical stability and provider recommendation for continuity

External Review and Complaints

California's Independent Medical Review (IMR) system is your strongest tool if Aetna denies coverage.

When You're Eligible for IMR

  • Medical necessity denials - Plan says Evrysdi isn't medically necessary
  • Experimental/investigational claims - Plan considers treatment unproven (rare for FDA-approved drugs)
  • Emergency or out-of-network disputes - Coverage disagreements for urgent care

How to File IMR

  1. Complete internal appeal first - File grievance with Aetna and wait up to 30 days
  2. Submit IMR application - Use DMHC's online portal within 6 months of final denial
  3. Include supporting documents - Medical records, provider letters, clinical literature
  4. Track your case - DMHC assigns independent physician reviewers in relevant specialty
  5. Receive binding decision - Standard IMR decided within 30 days; expedited within 7 days
Note: IMR decisions are binding on Aetna. If approved, they must authorize coverage within 5 days.

Consumer Complaint Process

For non-medical necessity issues (like processing delays or customer service problems), file a consumer complaint with DMHC at (888) 466-2219.

Practical Scripts and Documentation

Patient Phone Script for Aetna

"I'm calling about prior authorization for Evrysdi, generic name risdiplam, for spinal muscular atrophy. My doctor submitted the PA on [date] with genetic test results showing SMN1 deletion and baseline motor assessments. Can you confirm receipt and provide the review timeline? If there are any missing documents, please specify exactly what's needed."

Medical Necessity Letter Checklist

For providers writing appeals, include:

  • Problem statement: "Patient has genetically confirmed SMA Type [X] with documented motor function decline"
  • Prior treatments: Specific details on Spinraza/Zolgensma trials, outcomes, and reasons for discontinuation
  • Clinical rationale: Why Evrysdi is medically necessary based on patient's specific condition
  • Guideline support: Reference FDA labeling and SMA clinical guidelines
  • Monitoring plan: How you'll track treatment response and safety

Email Template for Documentation Requests

"Dear [Provider Office], I need documentation for my Evrysdi prior authorization with Aetna. Please provide: (1) Genetic test results showing SMN1 deletion, (2) Most recent motor function assessment scores, (3) Summary of any prior SMA treatments and outcomes. Please send within 48 hours to meet PA deadlines. Thank you."

Limits and Caveats

ERISA Plan Differences: Self-funded employer plans may have different appeal rights than state-regulated plans. However, most still must follow California's procedural protections for residents. Check your Summary Plan Description or contact HR to understand your specific appeal rights.

Medicare and Medicaid Variations:

  • Medicare Advantage: Follow Medicare appeal timelines (may differ from commercial)
  • Medi-Cal: Different PA requirements and appeal processes apply
  • Dual eligibles: Coordinate between programs for coverage

Geographic Considerations: These protections apply specifically to California residents with California-regulated plans. If you move or change to an out-of-state plan, different rules may apply.

Quick Reference Contacts

California Regulators

  • DMHC Help Center: (888) 466-2219 - healthhelp.ca.gov
  • California Department of Insurance: (800) 927-4357 for CDI-regulated plans

Patient Advocacy Resources

  • Health Consumer Alliance: Free legal aid for health insurance appeals - healthconsumer.org
  • DMHC Consumer Assistance: File complaints and get help with IMR applications

Aetna (CVS Health) Contacts

  • Prior Authorization: Submit via CVS Caremark portal (verify current link)
  • Member Services: Phone number on your insurance card
  • CVS Specialty Pharmacy: Coordinates Evrysdi dispensing once approved

Getting specialized help with your Evrysdi appeal? Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to create point-by-point rebuttals with the right clinical evidence and procedural requirements for each payer.

FAQ

How long does Aetna PA take for Evrysdi in California? Standard review takes 15-30 days, but California law requires response within regulatory timeframes or automatic approval. Expedited review available for urgent cases (72 hours maximum).

What if Evrysdi is non-formulary on my Aetna plan? Request a formulary exception with medical necessity documentation. California's step therapy protections under AB 347 may help if you meet exception criteria.

Can I request expedited appeal if denied? Yes, if your provider documents that delayed access poses significant health risks. California requires expedited appeals be decided within 72 hours for urgent cases.

Does step therapy apply if I failed treatments outside California? Yes, prior treatment failures from any location count toward step therapy requirements. Include complete medical records showing previous therapy attempts and outcomes.

What happens if Aetna doesn't respond to my PA request? California law may deem delayed responses as automatic approvals. Contact DMHC Help Center if your plan exceeds response timeframes.

Can I get help paying for Evrysdi while appeals are pending? Genentech offers patient assistance programs. Check eligibility at their official patient support website or ask your specialty pharmacy about temporary supply options.

When should I escalate to state regulators? File with DMHC if Aetna violates appeal timelines, denies medically necessary care, or fails to follow IMR decisions. Consumer complaints are free and can resolve issues quickly.

What documentation strengthens my Evrysdi appeal? Include genetic test results, baseline and follow-up motor assessments, specialist letters citing clinical guidelines, and detailed treatment history. Counterforce Health can help identify the specific evidence your plan requires.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider about treatment decisions and contact your insurance plan or California regulators for specific coverage questions.

Sources & Further Reading

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