By Counterforce Health Team in Evrysdi (risdiplam) —

How to Get Evrysdi (Risdiplam) Covered by Aetna CVS Health in North Carolina: Complete Prior Authorization and Appeal Guide

Answer Box: Quick Path to Evrysdi Coverage

Evrysdi (risdiplam) requires prior authorization from Aetna CVS Health in North Carolina. To get approved: 1) Have your neurologist submit genetic confirmation of SMA with biallelic SMN1 mutations, 2) Include baseline motor function assessments and treatment history, 3) Use Aetna's specialty prior authorization portal or complete their Evrysdi precertification form. Standard approval takes 15-30 days. If denied, North Carolina residents can appeal through Smart NC external review for binding decisions.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timeline and Urgency
  4. Clinical Criteria and Requirements
  5. Understanding Costs
  6. Denials and Appeals
  7. Renewals and Reauthorization
  8. CVS Specialty Pharmacy Process
  9. Troubleshooting Common Issues
  10. North Carolina-Specific Rights

Coverage Basics

Is Evrysdi Covered by Aetna CVS Health?

Yes, but prior authorization is required for all Aetna CVS Health plans in North Carolina. Evrysdi appears on Aetna's 2024 precertification list as a specialty medication requiring clinical review.

Which Plans Cover Evrysdi?

Coverage applies to:

  • Commercial Aetna plans
  • Medicare Advantage plans through CVS Health
  • Medicaid managed care plans (separate criteria apply)

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required before dispensing Aetna PA List
Genetic Testing Biallelic SMN1 mutations confirmed Clinical Policy Bulletin 4074-A
Specialist Prescription Neurologist or SMA specialist Aetna PA Form
Step Therapy May require trial/failure of alternatives Plan-specific formulary
Quantity Limits Weight-based dosing verified CVS Caremark

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Gather Required Documentation (Patient/Clinic)
    • Genetic test results showing biallelic SMN1 mutations
    • Clinical SMA diagnosis from neurologist
    • Baseline motor function assessments (CHOP INTEND, Hammersmith scales)
    • Prior therapy documentation (if applicable)
  2. Complete Aetna's Evrysdi Form (Provider)
  3. Submit via Preferred Method (Provider)
    • Online: Aetna provider portal (fastest)
    • Fax: Check form for current fax number
    • Expected processing: 5-7 business days
  4. Track Status (Patient/Provider)
    • Call Aetna Pharmacy Precertification: 1-866-814-5506
    • Check provider portal for updates
    • Response timeline: 15-30 days standard
  5. Coordinate with CVS Specialty (Patient)
    • Complete Evrysdi Start Form if approved
    • Enroll in specialty pharmacy services
    • Schedule delivery: 3-5 business days
Tip: Submit your PA request at least 2-3 weeks before you need the medication. This allows time for any additional documentation requests.

Timeline and Urgency

Standard Timeline

  • PA Review: 15-30 days
  • Expedited Review: 72 hours (if urgent medical need)
  • Appeal Response: 30 days internal, 45 days external review

When to Request Expedited Review

  • Life-threatening condition
  • Serious deterioration without treatment
  • Hospital discharge requiring immediate therapy

To request expedited review, have your doctor call Aetna at 1-866-814-5506 and clearly state the urgent medical necessity.

Clinical Criteria and Requirements

Aetna's Medical Necessity Criteria

Based on Clinical Policy Bulletin 4074-A, approval requires:

Essential Requirements:

  • Confirmed diagnosis of 5q-autosomal recessive SMA
  • Genetic testing showing biallelic SMN1 mutations
  • Prescription by neurologist experienced in SMA treatment
  • Baseline motor function assessment documented

Step Therapy Considerations: Aetna may require documentation of:

  • Previous trial and response to Spinraza (nusinersen) OR
  • Previous trial and response to Zolgensma (onasemnogene) OR
  • Medical contraindication to these alternatives OR
  • Clinical rationale for Evrysdi as first-line therapy
Clinician Corner: Your medical necessity letter should address: (1) specific SMA type and genetic confirmation, (2) current motor function status, (3) treatment goals and expected outcomes, (4) why Evrysdi is appropriate vs. alternatives, and (5) monitoring plan. Include references to FDA labeling and SMA treatment guidelines where applicable.

Common Denial Reasons & How to Fix Them

Denial Reason Documentation to Provide
"Genetic testing not confirmed" Submit SMN1 deletion/mutation report from certified lab
"Not prescribed by specialist" Letter from neurologist confirming SMA expertise
"Missing motor assessments" CHOP INTEND, Hammersmith, or RULM scores
"Step therapy not met" Document Spinraza/Zolgensma trial, failure, or contraindication
"Concurrent therapy" Confirm no overlapping SMA treatments

Understanding Costs

What You Might Pay

  • Commercial plans: Varies by tier (typically specialty tier with 20-40% coinsurance)
  • Medicare Advantage: Subject to Part D coverage rules
  • Medicaid: Typically covered with minimal copay

Financial Assistance Options

  • Genentech Patient Foundation: Need-based assistance (verify eligibility at Genentech Access)
  • CureSMA: Patient advocacy and resources
  • North Carolina pharmaceutical assistance programs: Contact NC 211 for local options

Denials and Appeals

Appeals Playbook for Aetna CVS Health in North Carolina

Level 1: Internal Appeal

  • Deadline: 180 days from denial notice
  • How to file: Call 1-866-814-5506 or submit via provider portal
  • Timeline: 30 days for standard, 72 hours for expedited
  • Required: Denial letter, additional clinical documentation, provider support letter

Level 2: Smart NC External Review

  • Who can use: North Carolina residents with state-regulated plans
  • Deadline: 120 days from final internal denial
  • How to file: Submit request to Smart NC
  • Timeline: 45 days standard, 72 hours expedited
  • Outcome: Binding decision on insurer
Note: Smart NC provides free advocacy support. Call 1-855-408-1212 to speak with insurance experts who can help you navigate the external review process.

Sample Appeal Script for Patients

"I'm calling to appeal the denial of Evrysdi for my [child/myself]. The denial letter is dated [date] and the reference number is [number]. This medication is FDA-approved for SMA, which has been confirmed by genetic testing. My neurologist has provided additional clinical documentation supporting medical necessity. I'd like to request an expedited appeal due to the progressive nature of SMA."

Renewals and Reauthorization

When to Reauthorize

  • Standard: Every 12 months
  • Plan changes: When switching Aetna products
  • Dosing changes: If weight-based dosing adjustments needed

What Documentation to Update

  • Current motor function assessments
  • Treatment response and tolerability
  • Any changes in clinical status
  • Updated prescriber attestation

Start the reauthorization process 30 days before expiration to avoid treatment gaps.

CVS Specialty Pharmacy Process

Enrollment Steps

  1. Provider submits Evrysdi Start Form to initiate access support
  2. CVS Specialty contacts patient for benefits verification and enrollment
  3. Patient completes health questionnaire and delivery preferences
  4. First shipment coordinated after PA approval

North Carolina Delivery Options

  • Home delivery (most common)
  • CVS Pharmacy locations (where available)
  • Healthcare provider office
  • Work address (with temperature-controlled handling)

Important: Answer calls from CVS Specialty promptly to avoid delays. They'll use local area codes or 1-800 numbers.

Troubleshooting Common Issues

Portal Problems

  • Can't access Aetna portal: Contact provider services at 1-800-624-0756
  • Form won't upload: Try PDF format under 10MB, or fax as backup

Missing Documentation

  • Genetic testing: Contact original testing lab for certified copy
  • Motor assessments: Schedule with SMA specialist if not current
  • Prior therapy records: Request from previous providers/pharmacies

Communication Delays

  • No response from Aetna: Call member services number on insurance card
  • CVS Specialty not calling: Contact them directly at 1-800-237-2767

North Carolina-Specific Rights

Smart NC External Review Program

North Carolina offers one of the strongest external review programs in the country. Key benefits:

  • Free service with expert advocacy support
  • Binding decisions that insurers must follow
  • Fast timelines (72 hours for urgent cases)
  • Broad coverage including experimental treatment denials

State Health Plan Coverage

If you're covered by the North Carolina State Health Plan, similar appeal rights apply with some variations in process.

Consumer Resources

  • Smart NC Helpline: 1-855-408-1212
  • NC Department of Insurance: Consumer assistance and complaint filing
  • Health Insurance Smart NC: Online guides and sample appeal letters

FAQ: Most Common Questions

Q: How long does Aetna CVS Health prior authorization take for Evrysdi in North Carolina? A: Standard review takes 15-30 days. Expedited reviews for urgent medical needs are completed within 72 hours.

Q: What if Evrysdi is not on my Aetna formulary? A: You can request a formulary exception with clinical documentation showing medical necessity and lack of suitable alternatives.

Q: Can I get an expedited appeal if my initial request is denied? A: Yes, if you can demonstrate urgent medical need or risk of serious harm from treatment delay.

Q: Does step therapy apply if I previously tried Spinraza outside North Carolina? A: Yes, prior therapy documentation from any location counts toward step therapy requirements if properly documented.

Q: What genetic testing does Aetna accept for SMA confirmation? A: Any certified laboratory report confirming biallelic SMN1 mutations. The testing doesn't need to be repeated if you have existing results.

Q: How does Smart NC external review work for rare diseases like SMA? A: Smart NC assigns Independent Review Organizations with rare disease expertise. The review is binding and often more favorable for complex cases than internal appeals.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, identifies the specific denial basis, and drafts point-by-point rebuttals aligned to each payer's own rules—pulling the right medical evidence and clinical documentation to support SMA treatments like Evrysdi.

For additional support navigating Aetna's prior authorization process, Counterforce Health provides specialized assistance with complex specialty medication appeals, helping ensure patients get access to FDA-approved treatments for rare diseases.

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 policies with your insurer and consult your healthcare provider for medical decisions. For official North Carolina insurance regulations and consumer rights, visit the NC Department of Insurance website.

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