By Counterforce Health Team in Evrysdi (risdiplam) —

How to Get Evrysdi (Risdiplam) Covered by Aetna in Ohio: Appeal Guide with Forms and Timelines

Answer Box: Getting Evrysdi Covered by Aetna in Ohio

Fastest path to approval: Submit genetic testing documentation confirming biallelic SMN1 mutations, clinical SMA diagnosis, baseline motor assessments, and prior therapy history to Aetna's prior authorization process. If denied, file an internal appeal within 180 days, then request external review through Ohio Department of Insurance if needed. Start today: Contact your neurologist to gather genetic test results and motor function scores, then call Aetna member services to confirm current PA requirements.

Table of Contents

  1. Read Your Denial Letter
  2. Coverage Requirements at a Glance
  3. Step-by-Step: Fastest Path to Approval
  4. Common Denial Reasons & How to Fix Them
  5. Appeals Playbook for Aetna in Ohio
  6. Medical Necessity Letter Essentials
  7. External Review Process in Ohio
  8. Scripts and Templates
  9. When Appeals Fail: Next Steps
  10. FAQ

Read Your Denial Letter

Your Aetna denial letter contains critical information that determines your next steps. Look for these key elements:

Denial reason codes typically fall into these categories:

  • Medical necessity not established - Missing clinical documentation
  • Non-formulary drug - Evrysdi isn't on your plan's preferred list
  • Step therapy required - Must try Spinraza or other SMA treatments first
  • Insufficient documentation - Missing genetic testing or motor assessments

Appeal deadlines are usually 180 days from the denial date for internal appeals. External review requests must be filed within 180 days of your final internal denial.

Benefit type matters: Evrysdi may be covered under your medical benefit (administered by Aetna) or pharmacy benefit (managed by CVS Caremark). This affects which forms you use and where you submit appeals.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before coverage Aetna PA List Aetna
Genetic Testing Biallelic SMN1 mutations confirmed CLIA-certified lab report Aetna Policy 0140
Clinical Diagnosis SMA Type 1, 2, or 3 documented Neurologist assessment Aetna Medical Policy
Motor Assessment Baseline function scores required CHOP INTEND, Hammersmith scales Clinical Guidelines
Ventilator Status No invasive ventilation dependency Medical records Coverage Criteria
Age Requirements Pediatric and adult patients eligible FDA labeling FDA Access Data

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation

Who: Patient and clinic staff
Documents needed:

  • Genetic test report showing biallelic SMN1 mutations
  • Clinical notes confirming SMA diagnosis and type
  • Baseline motor function assessments
  • Prior SMA therapy history (if applicable)

2. Submit Prior Authorization Request

Who: Prescribing neurologist
How: Fax to 1-855-296-0323 for pharmacy benefits or submit via Aetna provider portal
Timeline: 15-30 days for standard review
Source: CVS Caremark PA Process

3. Address Missing Information Promptly

Who: Clinic staff
Action: Respond to any Aetna requests for additional documentation within 14 days
Documents: Often motor assessment scores or genetic testing clarification

4. Request Peer-to-Peer Review (if initially denied)

Who: Prescribing physician
How: Call Aetna medical management at number on denial letter
Prep: Have patient chart, FDA labeling, and clinical rationale ready

5. File Internal Appeal if Denied

Who: Patient or authorized representative
How: Written appeal to address on denial letter
Timeline: Must file within 180 days of denial
Documents: Medical necessity letter, supporting clinical evidence

6. Request External Review (if internal appeal fails)

Who: Patient
How: Submit request to Aetna, who forwards to Ohio Department of Insurance
Timeline: 30 days for standard review, 72 hours for expedited
Source: Ohio DOI External Review

7. Consider Step Therapy Exception

Who: Prescribing physician
How: Document contraindications or failures with preferred SMA treatments
Form: Aetna step therapy exception request

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Genetic testing insufficient" Submit complete CLIA lab report Full genetic analysis showing biallelic SMN1 mutations
"Medical necessity not established" Provide clinical rationale letter SMA type, symptoms, functional decline documentation
"Step therapy not completed" Request exception or document failures Prior Spinraza/Zolgensma contraindications or inadequate response
"Non-formulary drug" File formulary exception Comparative effectiveness data, intolerance to alternatives
"Experimental/investigational" Cite FDA approval FDA labeling for SMA indication, peer-reviewed efficacy data

Appeals Playbook for Aetna in Ohio

Internal Appeals

Level 1: Standard internal appeal

  • Deadline: 180 days from denial
  • Timeline: 30 days for standard, 72 hours for expedited
  • How to file: Written request to address on denial letter
  • Required: Medical necessity letter, clinical documentation

Level 2: Second-level internal appeal (if available)

  • Deadline: 60 days from first-level denial
  • Process: Automatic for some denials, request for others

External Review in Ohio

Ohio provides an independent external review process for medical necessity denials:

Eligibility: Medical judgment or information disputes
Timeline: File within 180 days of final internal denial
Process: Submit to Aetna, who forwards to Ohio Department of Insurance
Decision time: 30 days standard, 72 hours expedited
Outcome: Binding decision on both parties

Contact for help: Ohio Department of Insurance Consumer Services at 1-800-686-1526

Medical Necessity Letter Essentials

Clinician Corner: Your medical necessity letter is the cornerstone of a successful appeal. Include these elements:

Required Components:

  1. Patient identification and SMA diagnosis with ICD-10 codes
  2. Genetic confirmation - Specific SMN1 mutation details
  3. Clinical presentation - SMA type, current symptoms, functional status
  4. Baseline motor assessments - CHOP INTEND, Hammersmith scores, or similar
  5. Prior treatments - Previous SMA therapies, outcomes, reasons for discontinuation
  6. Treatment rationale - Why Evrysdi is medically necessary for this patient
  7. Contraindications - Why alternatives aren't appropriate
  8. Monitoring plan - How you'll assess treatment response

Supporting Evidence:

  • FDA labeling for Evrysdi
  • SMA treatment guidelines from neuromuscular societies
  • Peer-reviewed studies supporting efficacy
  • Patient-specific clinical notes and test results

Counterforce Health specializes in transforming insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each plan's requirements.

External Review Process in Ohio

When Aetna's internal appeals are exhausted, Ohio residents can request an independent external review:

Process Overview:

  1. Submit request to Aetna within 180 days of final denial
  2. Aetna forwards to Ohio Department of Insurance
  3. Independent Review Organization (IRO) assigned randomly
  4. Medical experts review case using clinical evidence
  5. Binding decision issued within 30 days (72 hours if expedited)

Required Documentation:

  • Copy of final denial letter from Aetna
  • All medical records and clinical notes
  • Any new evidence not previously submitted
  • Patient statement (optional but recommended)

Expedited Review Criteria:

  • Delay would seriously jeopardize health
  • Delay would jeopardize ability to regain maximum function
  • Physician certifies urgency

Ohio DOI Contact: External Review Information

Scripts and Templates

Patient Phone Script for Aetna

"Hello, I'm calling about a prior authorization denial for Evrysdi (risdiplam) for spinal muscular atrophy. My member ID is [X]. Can you please:

  • Confirm the specific denial reason
  • Provide the appeals deadline
  • Send me the appeal form
  • Connect me with a case manager if available"

Peer-to-Peer Request Script for Clinicians

"I'm requesting a peer-to-peer review for [patient name], member ID [X], regarding denied coverage for Evrysdi. The patient has genetically confirmed SMA with [specific details]. I have clinical documentation showing medical necessity. When can we schedule this review?"

Email Template for Medical Records

"Subject: Urgent - Medical Records Needed for Insurance Appeal

We need the following records for [patient name]'s Evrysdi appeal by [date]:

  • Genetic testing report (SMN1 analysis)
  • Motor function assessments from [dates]
  • Clinical notes from [dates]
  • Prior therapy documentation

Please fax to [number] or secure email to [address]. Thank you."

When Appeals Fail: Next Steps

If your external review is denied, consider these options:

Alternative Coverage Strategies:

  • Formulary alternatives - Discuss Spinraza or Zolgensma with your neurologist
  • Different insurance - Explore options during open enrollment
  • Medicaid eligibility - May have different coverage criteria

Financial Assistance:

  • Genentech Access Solutions - Manufacturer patient assistance program
  • Foundation grants - Disease-specific organizations may provide funding
  • State programs - Ohio may have rare disease assistance programs
  • File complaint with Ohio Department of Insurance
  • Contact state legislators - May advocate for coverage policy changes
  • Legal consultation - For potential ERISA or bad faith claims

For complex appeals involving multiple denial reasons and payer-specific workflows, Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by providing evidence-backed rebuttals tailored to each plan's specific requirements.

FAQ

How long does Aetna prior authorization take in Ohio? Standard PA decisions take 15-30 days. Expedited reviews (for urgent medical needs) are completed within 72 hours. [Source: Aetna PA Guidelines]

What if Evrysdi is non-formulary on my Aetna plan? You can request a formulary exception by demonstrating medical necessity and providing evidence that preferred alternatives are inappropriate or ineffective for your specific case.

Can I request an expedited appeal for Evrysdi? Yes, if your physician certifies that a delay in treatment would seriously jeopardize your health or ability to regain maximum function. Expedited appeals are decided within 72 hours.

Does step therapy apply if I've tried SMA treatments in another state? Yes, prior treatment history from any location counts toward step therapy requirements. Ensure your medical records are transferred and include detailed documentation of previous therapies and outcomes.

What happens if I miss the appeal deadline? You may request a deadline extension if you can show good cause for the delay (such as not receiving the denial notice). Contact Aetna member services immediately to discuss options.

How much does Evrysdi cost without insurance? List pricing can reach approximately $340,000 annually, with individual bottles costing around $11,000. Weight-based dosing means smaller patients pay less. [Source: Industry pricing data]

Can my specialty pharmacy help with the appeal? Yes, many specialty pharmacies have dedicated patient assistance teams that help with prior authorizations, appeals, and documentation. They often coordinate directly with your physician's office.

What's the success rate for Evrysdi appeals with Aetna? Specific success rates aren't publicly available, but appeals supported by comprehensive genetic testing, clinical documentation, and clear medical necessity statements have significantly higher approval rates than incomplete submissions.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures may change. Always verify current requirements with your insurance plan and consult with your healthcare provider about treatment decisions. For personalized assistance with insurance coverage issues, contact the Ohio Department of Insurance Consumer Services at 1-800-686-1526.

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