By Counterforce Health Team in Evrysdi (risdiplam) —

How to Get Evrysdi (risdiplam) Covered by Aetna (CVS Health) in Pennsylvania: Forms, Appeals, and Contact Guide

Quick Answer: Evrysdi (risdiplam) requires prior authorization from Aetna (CVS Health) in Pennsylvania. Submit PA requests via the Availity provider portal with genetic confirmation, neurologist documentation, and motor function assessments. If denied, you have 180 days to appeal internally, then 4 months for Pennsylvania's external review program. Start by verifying your specific plan's formulary requirements and gathering all clinical documentation.

Table of Contents

Start Here: Verify Your Plan and Coverage

Before starting the prior authorization process, you'll need to confirm your specific Aetna plan details and Evrysdi's coverage status.

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all Evrysdi prescriptions Aetna 2024 Precertification List
Formulary Status Covered with restrictions Your plan's drug formulary
Step Therapy May apply (varies by plan) Member portal or call customer service
Quantity Limits FDA-approved dosing only Plan documents
Specialty Pharmacy CVS Caremark required Member ID card

First Steps:

  1. Log into your Aetna member portal or call the number on your ID card to verify Evrysdi is covered under your specific plan
  2. Check if you have commercial, Medicare, or Medicaid coverage - submission processes differ
  3. Confirm your plan requires CVS Caremark for specialty medications

Prior Authorization Forms and Requirements

Aetna requires comprehensive clinical documentation to approve Evrysdi for spinal muscular atrophy (SMA).

Required Clinical Documentation

Your neurologist must provide:

  • Confirmed SMA diagnosis with genetic testing results (SMN gene mutation or deletion at 5q13)
  • ICD-10 diagnosis codes for SMA type
  • Baseline motor function assessment by a neurologist experienced with SMA
  • Weight-based dosing calculation consistent with FDA labeling
  • Confirmation that Evrysdi will not be used simultaneously with Spinraza (nusinersen)
  • Documentation of contraindications to other SMA treatments (if step therapy applies)

Clinician Corner: Medical Necessity Letter Checklist

For Prescribers: Your medical necessity letter should include:Patient's specific SMA type and genetic confirmationCurrent motor function status and assessment tools usedPrevious SMA treatments tried and outcomes (if applicable)Clinical rationale for Evrysdi vs. alternativesDosing plan based on patient weightMonitoring schedule and treatment goals

Reference the FDA prescribing information and relevant neurology society guidelines in your documentation.

Submission Portals and Methods

Primary Submission Method: Availity Portal

For most Aetna plans:

  • Use the Availity provider portal for electronic PA submissions
  • Create an account if you don't have one (requires provider credentials)
  • Submit requests at least 2 weeks in advance to avoid delays
  • Upload all required clinical documentation directly

Alternative Submission Options

For Aetna Better Health (Medicaid):

Phone Support:

  • Commercial plans: 1-888-632-3862 (TTY: 711)
  • Medicare plans: 1-800-624-0756 (TTY: 711)
  • Medicaid plans: 1-866-638-1232 (TTY: 711)

Fax Numbers and Mailing Addresses

CVS Caremark Specialty Programs

  • Fax: 1-866-237-5512
  • Use this for Evrysdi specialty enrollment and PA forms

Aetna Provider Appeals

  • National appeals fax: 859-455-8650

Mailing address:

Aetna Provider Resolution Team
PO Box 981106
El Paso, TX 79998-1106

Cover Sheet Tips

  • Include member ID, provider NPI, and "URGENT - SMA Treatment Request" if expedited review is needed
  • List all attached documents clearly
  • Include direct callback number for questions

CVS Caremark Specialty Pharmacy Setup

Most Aetna plans require CVS Caremark for specialty medications like Evrysdi.

Enrollment Steps

  1. Complete prior authorization first - PA approval is required before specialty enrollment
  2. Contact CVS Caremark Specialty at the number on your member ID card
  3. Provide transfer information if switching from another specialty pharmacy
  4. Coordinate with your prescriber for prescription transmission

Transfer Process

If you're currently using another specialty pharmacy:

  • CVS Caremark will coordinate the transfer of your prescription and medical records
  • Allow extra time for the transfer process to avoid treatment interruption
  • Confirm your current pharmacy has released your prescription

Member and Provider Support Lines

Member Services

  • General inquiries: Number on your member ID card
  • Pharmacy benefits: Available 24/7 for coverage questions
  • Appeals assistance: Request supervisor if initial representative can't help

Provider Relations

  • Prior authorization status: Use Availity portal or call provider services
  • Peer-to-peer reviews: Available if initial PA is denied
  • Expedited requests: Available for urgent medical situations

What to Ask When You Call

  • "What specific clinical documentation is missing for my Evrysdi PA?"
  • "Can I request an expedited review due to medical urgency?"
  • "What are my plan's specific step therapy requirements for SMA medications?"

Pennsylvania Appeals and External Review

Pennsylvania offers one of the strongest patient appeal processes in the country.

Internal Appeals Timeline

  1. File with Aetna within 180 days of denial
  2. Standard review: Up to 45 business days
  3. Expedited review: 72 hours for urgent cases
  4. Submit additional documentation during review period

Pennsylvania External Review Program

If Aetna denies your internal appeal, Pennsylvania's Independent External Review Program provides a second chance.

Key Benefits:

  • 50% overturn rate in the program's first year
  • Independent physician reviewers not affiliated with your insurer
  • Binding decisions - if approved, Aetna must cover the treatment

Contact Information:

Timeline:

  • Request deadline: 4 months after final Aetna denial
  • Standard review: 45 days
  • Expedited review: 72 hours (with physician certification)

Common Denial Reasons and Solutions

Denial Reason How to Overturn
Missing genetic testing Submit SMN gene deletion/mutation results
Inadequate motor assessment Provide detailed neurologist evaluation with standardized scales
Duplicate therapy concern Document why other SMA treatments are contraindicated
Non-formulary status Request formulary exception with medical necessity letter
Dosing concerns Include weight-based calculation per FDA labeling

From Our Advocates

We've seen many Evrysdi approvals succeed when families work closely with their neurologist to submit comprehensive genetic and motor function documentation upfront. One common issue is incomplete baseline assessments - make sure your specialist includes detailed motor function scores and explains why Evrysdi is the most appropriate choice for your specific situation.

Costs and Patient Assistance

Evrysdi can cost up to $340,000 annually, making patient assistance crucial.

Manufacturer Support

  • Genentech Patient Foundation provides assistance for eligible patients
  • Copay support programs may be available for commercial insurance
  • Visit Genentech's patient resources for current programs

Pennsylvania-Specific Resources

  • Pennsylvania CHIP covers SMA treatments for eligible children
  • Medicaid coverage through PA Department of Human Services
  • Patient advocacy organizations like Cure SMA offer navigation support

FAQ

How long does Aetna prior authorization take for Evrysdi in Pennsylvania? Standard PA decisions typically take 30-45 days, but expedited reviews are available within 72 hours for urgent cases. Submit requests at least 2 weeks in advance.

What if Evrysdi is not on my Aetna formulary? You can request a formulary exception with medical necessity documentation. Your neurologist should explain why Evrysdi is medically necessary and other treatments are inappropriate.

Can I appeal if I'm denied for step therapy requirements? Yes. Document medical contraindications, intolerance, or lack of efficacy with previous SMA treatments. Peer-to-peer reviews with Aetna's medical director are often helpful.

Does Pennsylvania's external review apply to all Aetna plans? The state external review covers most individual and employer plans but excludes self-funded ERISA plans. Check with Pennsylvania Insurance Department if you're unsure about your plan type.

What happens if I need Evrysdi urgently while waiting for approval? Request an expedited PA review and consider manufacturer compassionate use programs. Your neurologist can also request a peer-to-peer discussion with Aetna's medical team.

When Treatment Can't Wait

If you need Evrysdi urgently while navigating insurance approval, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and drafts point-by-point rebuttals aligned with your specific plan's requirements, helping patients and clinicians get prescription drugs approved faster.

For immediate assistance with complex cases, contact the Pennsylvania Insurance Department's consumer services at 1-888-466-2787, or reach out to patient advocacy organizations like Cure SMA for navigation support.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for guidance specific to your situation. Coverage policies and requirements may change - verify current information with official sources.

Sources & Further Reading

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