By Counterforce Health Team in Evrysdi (risdiplam) —

How to Get Evrysdi (risdiplam) Covered by Aetna CVS Health in New York: Complete PA Guide with Appeals Process

Answer Box: Getting Evrysdi (risdiplam) Covered by Aetna CVS Health in New York

Evrysdi (risdiplam) is covered by Aetna CVS Health in New York, but requires prior authorization with genetic testing confirmation and specialist prescription. The fastest path to approval: (1) Ensure your neurologist or geneticist has documented SMA diagnosis with biallelic SMN1 mutations, (2) Submit PA via Aetna's provider portal with baseline motor assessments and weight-based dosing calculations, (3) If denied, use New York's external appeal process through the Department of Financial Services within 4 months. Start with Aetna's drug search tool to verify your plan's specific requirements.

Table of Contents

  1. Plan Types & Coverage Implications
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. CVS Specialty Pharmacy Process
  5. Cost-Share Basics
  6. Submission Process & Forms
  7. Common Approval Patterns
  8. Appeals Process in New York
  9. FAQ
  10. Sources & Further Reading

Plan Types & Coverage Implications

Your Aetna CVS Health plan type affects how you access neurologists and geneticists who prescribe Evrysdi:

HMO Plans: You'll need a referral from your primary care physician (PCP) to see a neurologist or geneticist. Referrals are valid for 90 days and must be obtained before your specialist visit.

PPO Plans: No referral required—you can directly schedule with in-network specialists. This often speeds up the process for getting your Evrysdi prescription initiated.

EPO Plans: Referral requirements vary by specific plan. Check your plan documents or call member services, as many newer EPO plans don't require referrals for specialists.

Tip: If you have an HMO and need urgent access to a neurologist, ask your PCP about expedited referrals for rare disease management.

Formulary Status & Tier Placement

Evrysdi appears on Aetna's 2024 precertification list as a specialty medication requiring clinical review across commercial, Medicare Advantage, and Medicaid managed care plans.

Formulary Coverage:

  • Listed: Evrysdi is typically on formulary but requires prior authorization
  • Specialty Tier: Usually placed on the highest cost-sharing tier (often 25-40% coinsurance)
  • Quantity Limits: Weight-based dosing must align with FDA-approved guidelines

Alternative Agents: If Evrysdi is denied, your doctor may need to document why other SMA treatments (Spinraza, Zolgensma) aren't appropriate based on clinical factors, patient preference, or previous treatment history.

Prior Authorization Requirements

Aetna requires comprehensive documentation for Evrysdi approval. Here's what your healthcare team needs to submit:

Coverage at a Glance

Requirement What It Means Where to Find It Source
Genetic Testing Biallelic SMN1 mutations (5q13) Lab results from certified genetics lab Aetna Clinical Policy 4074-A
Specialist Prescription Neurologist or geneticist must prescribe Provider credentials verification PA Form Requirements
Baseline Motor Assessment Current functional status documentation Clinical notes, standardized scales Medical Necessity
Weight-Based Dosing FDA-approved calculations by weight/age Prescriber dosing guide FDA Label
Prior Treatments History of other SMA therapies or contraindications Medical records, prior auth documents Clinical Documentation

Clinician Corner: Medical Necessity Letter Checklist

Your specialist should include these elements in the prior authorization:

✓ Confirmed SMA diagnosis with genetic testing results
✓ Current motor function using standardized assessments (CHOP-INTEND, HFMSE, etc.)
✓ Weight and dosing calculations following FDA guidelines
✓ Previous SMA treatments and outcomes (if applicable)
✓ Clinical rationale for choosing Evrysdi over alternatives
✓ Treatment goals and monitoring plan

CVS Specialty Pharmacy Process

Evrysdi must be dispensed through CVS Caremark Specialty Pharmacy for most Aetna plans.

Step-by-Step: Specialty Pharmacy Enrollment

  1. Provider submits prescription to CVS Specialty after PA approval
  2. Patient enrollment via phone call from CVS Specialty (answer promptly to avoid delays)
  3. Insurance verification and copay assistance coordination
  4. Medication preparation from powder to ready-to-use liquid
  5. Home delivery with temperature-controlled shipping
  6. Storage instructions provided (refrigerate 2°C to 8°C, never freeze)
  7. Ongoing refill management with monthly coordination calls
Note: The constituted liquid expires 64 days after preparation, so proper storage and timely use are critical.

Cost-Share Basics

Specialty medications like Evrysdi typically have high out-of-pocket costs. Understanding your plan's structure helps with financial planning:

Typical Cost-Sharing:

  • Deductible: May apply before coinsurance kicks in
  • Specialty Tier: Often 25-40% coinsurance after deductible
  • Out-of-Pocket Maximum: Annual cap provides some protection

Manufacturer Support:

  • Genentech offers copay assistance programs
  • Patient assistance programs may be available based on income
  • Foundation grants may help with remaining costs

This is educational information only—consult your plan documents for specific cost-sharing details.

Submission Process & Forms

For Providers

Electronic Submission: Use Aetna's Availity portal for fastest processing.

Required Documentation:

  • Completed prior authorization form
  • Genetic testing results
  • Clinical notes with motor assessments
  • Weight-based dosing calculations
  • Previous treatment history (if applicable)

Timeline: Submit at least 2 weeks before needed start date. Standard decisions typically take 15-30 days.

For Patients

Phone Script for Member Services: "Hi, I need to verify prior authorization requirements for Evrysdi, spelled E-V-R-Y-S-D-I, for spinal muscular atrophy. My member ID is [number]. Can you confirm if my plan covers this medication and what documentation my doctor needs to submit?"

Common Approval Patterns

Based on successful submissions, strong prior authorizations typically include:

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documents
Missing genetic confirmation Resubmit with SMN1 testing Certified lab results
Inadequate motor assessment Provide baseline functional scores Standardized assessment tools
Dosing documentation gaps Include weight-based calculations FDA dosing guidelines
"Experimental" determination Submit FDA approval evidence FDA label, clinical guidelines
Step therapy requirement Document contraindications to alternatives Medical records, specialist notes

Appeals Process in New York

New York provides robust appeal rights for Aetna members, including external review through the Department of Financial Services.

Internal Appeals with Aetna

Timeline: File within 180 days of denial
Process: Submit through member portal or mail
Decision Time: Standard appeals decided within 30 days; expedited within 72 hours for urgent needs

New York State External Appeals

If Aetna's internal appeal is denied, you have additional rights under New York law:

Who Can File: Members or providers
Timeline: Within 4 months of final Aetna denial
Cost: $25 for members (waived for Medicaid/financial hardship), $50 for providers
Process: Independent medical experts review your case
Decision: Binding on Aetna if overturned

When to Escalate

Contact Community Health Advocates at 888-614-5400 for free help with appeals. They can assist New Yorkers with filing appeals and understanding your rights.

From our advocates: "We've seen Aetna denials overturned when families included published SMA treatment guidelines alongside their genetic testing results. The external reviewers in New York often reference medical literature in their decisions, so comprehensive documentation makes a difference."

FAQ

How long does Aetna CVS Health prior authorization take for Evrysdi in New York?
Standard decisions typically take 15-30 days. Expedited reviews for urgent medical needs are decided within 72 hours.

What if Evrysdi is non-formulary on my plan?
Request a formulary exception with medical necessity documentation. Your doctor can appeal based on clinical need and lack of suitable alternatives.

Does step therapy apply if I've tried other SMA treatments outside New York?
Yes, document previous treatments regardless of where they occurred. This strengthens your case for Evrysdi approval.

Can I request an expedited appeal?
Yes, if delay would seriously jeopardize your health. Both Aetna and New York's external review offer expedited timelines.

What counts as medical necessity for Evrysdi?
Confirmed SMA diagnosis with genetic testing, appropriate specialist prescribing, and clinical documentation of need.

Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed submissions. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements by identifying denial reasons and crafting point-by-point rebuttals aligned to each payer's specific policies. Learn more about our approach to streamlining the approval process for specialty medications like Evrysdi.

If you're facing an Aetna denial for Evrysdi in New York, remember that you have strong appeal rights under state law. The combination of Aetna's internal process and New York's external review system provides multiple opportunities to overturn inappropriate denials. With proper documentation and understanding of the requirements, many patients successfully obtain coverage for this important SMA treatment. For additional support with your appeal, Counterforce Health can help ensure your submission meets all payer-specific requirements.

Sources & Further Reading

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 verify current requirements with Aetna CVS Health and consult with your healthcare providers for medical decisions. For personalized help with insurance appeals, contact Community Health Advocates or the New York State Department of Financial Services.

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