By Counterforce Health Team in Evrysdi (risdiplam) —

How to Get Evrysdi (risdiplam) Covered by Blue Cross Blue Shield in Washington: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Evrysdi Covered by Blue Cross Blue Shield in Washington

Blue Cross Blue Shield plans in Washington (primarily Premera and Regence) require prior authorization for Evrysdi (risdiplam) with strict medical necessity criteria. Success requires genetic confirmation of SMA, specialist prescriber, baseline motor assessments, and documentation that concurrent SMN therapies aren't being used. If denied, you have 180 days for internal appeals, then can request external review through Washington's Office of the Insurance Commissioner. External reviews overturn approximately 40% of denials nationwide.

First step today: Call the number on your Blue Cross Blue Shield ID card to confirm your specific plan's Evrysdi policy and prior authorization requirements.

Table of Contents

  1. Understanding Blue Cross Blue Shield Coverage in Washington
  2. Prior Authorization Requirements
  3. Step-by-Step: Fastest Path to Approval
  4. Common Denial Reasons & How to Fix Them
  5. Appeals Process for Washington Blue Cross Blue Shield
  6. External Review Through Washington State
  7. Cost Assistance and Support Programs
  8. When to Escalate to State Regulators

Understanding Blue Cross Blue Shield Coverage in Washington

In Washington state, Blue Cross Blue Shield coverage is primarily provided by two independent carriers:

  • Premera Blue Cross (serving Washington and Alaska)
  • Regence BlueShield (part of the Cambia Health Solutions family)

Both carriers treat Evrysdi as a specialty drug requiring prior authorization. The medication is typically covered under the pharmacy benefit rather than medical benefit, though this varies by specific plan design.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all plans Premera PA List
Formulary Tier Specialty tier (high copay) Plan-specific drug list on ID card
Step Therapy Varies by plan Must verify with benefits investigation
Prescriber Requirement Neurologist or SMA specialist Plan medical policy
Genetic Confirmation SMN1 deletion/mutation required Clinical documentation
Appeals Deadline 180 days from denial Denial letter instructions

Prior Authorization Requirements

Blue Cross Blue Shield plans in Washington follow consistent criteria for Evrysdi approval, based on FDA labeling and clinical guidelines:

Core Clinical Requirements

Diagnosis Documentation:

  • Confirmed spinal muscular atrophy (Types I, II, III, or IV)
  • Genetic testing showing SMN1 gene deletion or mutation
  • SMN2 copy number when available
  • Appropriate ICD-10 codes (G12.0 for Type I, G12.1 for other inherited types)

Prescriber Qualifications:

  • Neurologist, neuromuscular specialist, or geneticist
  • Experience treating SMA patients
  • Documentation of specialist consultation if prescribed by primary care

Clinical Status Requirements:

  • Baseline motor function assessment (HINE, CHOP-INTEND, HFMSE, or RULM)
  • Current weight for dose calculation
  • Respiratory and feeding status documentation
  • Age-appropriate functional expectations

Treatment History:

  • Documentation of prior SMA therapies (if any)
  • Rationale for not using Spinraza or Zolgensma
  • Confirmation that patient isn't receiving concurrent SMN-modifying therapy
Clinician Corner: Medical necessity letters should address each criterion explicitly. Include genetic test results, functional scores, treatment goals, and why oral therapy is appropriate for this patient's circumstances.

Step-by-Step: Fastest Path to Approval

Step 1: Verify Coverage and Requirements

Who does it: Patient or clinic staff
Action: Call Blue Cross Blue Shield member services
Timeline: Same day
Documents needed: Insurance ID card

Step 2: Benefits Investigation

Who does it: Clinic or MySMA Support
Action: Submit benefits verification request
Timeline: 2-3 business days
Documents needed: Insurance information, patient demographics

Step 3: Gather Clinical Documentation

Who does it: Healthcare team
Action: Compile required medical records
Timeline: 1-2 weeks
Documents needed: Genetic reports, motor assessments, clinic notes

Step 4: Submit Prior Authorization

Who does it: Prescribing physician
Action: Complete PA form with supporting documentation
Timeline: Same day submission
Portal: Plan-specific provider portal or fax

Step 5: Follow Up on Decision

Who does it: Clinic staff
Action: Track PA status and respond to requests
Timeline: 14-15 business days for standard review
Next step: Appeal if denied

Step 6: Appeal if Necessary

Who does it: Patient with physician support
Action: Submit internal appeal with additional evidence
Timeline: Within 180 days of denial
Forms: Plan-specific member appeal form

Step 7: External Review (if needed)

Who does it: Patient
Action: Request independent review through Washington OIC
Timeline: Within 180 days of final internal denial
Contact: Washington Insurance Commissioner at 1-800-562-6900

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Lack of genetic confirmation Submit genetic test results SMN1 deletion/mutation report
Missing baseline assessment Provide motor function scores HINE, CHOP-INTEND, HFMSE, or RULM
Concurrent therapy concern Clarify treatment status Documentation that other SMN therapies discontinued
Prescriber not qualified Specialist consultation Neurology or genetics consultation note
Dosing documentation gaps Weight-based calculation Current weight and dose justification
"Experimental" determination FDA approval evidence FDA labeling and clinical guidelines

Appeals Process for Washington Blue Cross Blue Shield

Internal Appeals

Premera Blue Cross Appeals:

  • Deadline: 180 days from denial notice
  • Submission: Mail to Premera Blue Cross, ATTN: Member Appeals, PO Box 91102, Seattle, WA 98111-9202
  • Fax: (425) 918-5592
  • Timeline: 30 days for standard, 72 hours for expedited
  • Second level: Available within 30 days of first-level denial

Regence BlueShield Appeals:

  • Deadline: 180 days from denial notice (verify in denial letter)
  • Submission: Online portal or mail
  • Timeline: Similar to industry standard (30 days)
  • Forms: Use plan-specific member appeal forms

Key Appeal Strategies

  1. Address each denial reason specifically
  2. Include new supporting evidence
  3. Request peer-to-peer review with SMA specialist
  4. Cite relevant medical literature
  5. Emphasize consequences of treatment delay
Tip: Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and plan policies to create point-by-point rebuttals.

External Review Through Washington State

If internal appeals fail, Washington provides strong consumer protections through independent external review.

External Review Process

Eligibility:

  • Must complete internal appeals first
  • Denial involves medical necessity, appropriateness, or experimental designation
  • Request within 180 days of final internal denial

How to Request:

  • Contact Washington Office of the Insurance Commissioner
  • Phone: 1-800-562-6900
  • Online request form

Timeline:

  • Standard review: 45 days
  • Expedited review: 72 hours for urgent cases
  • Decision is binding on the insurance company

Success Rates: External reviews overturn approximately 40% of denials nationwide. For rare disease medications like Evrysdi, success rates improve when:

  • Clinical criteria are clearly met
  • Specialist support is strong
  • FDA approval status is emphasized
  • Medical necessity is well-documented

Cost Assistance and Support Programs

Manufacturer Support Programs

Evrysdi Co-pay Program:

  • Reduces copay to as low as $0
  • Annual maximum benefit up to $25,000
  • Eligibility check available online

MySMA Support:

  • Free benefits investigation
  • Prior authorization assistance
  • Appeal support resources
  • Contact information

Evrysdi Starter Program:

  • Temporary supply while coverage is pending
  • Up to 60 days of medication
  • Available for eligible patients

Additional Resources

  • Washington Apple Health (Medicaid): May cover Evrysdi with prior authorization
  • CureSMA organization: Patient advocacy and support
  • Foundation grants: Various rare disease foundations offer assistance

When navigating insurance challenges, Counterforce Health specializes in transforming coverage denials into successful appeals by leveraging plan-specific policies and evidence-based medical documentation.

When to Escalate to State Regulators

Contact the Washington Office of the Insurance Commissioner if you experience:

  • Improper denial procedures: Missing deadlines, inadequate review
  • Policy violations: Not following stated coverage criteria
  • Access barriers: Unreasonable delays or requirements
  • Appeals process failures: Not providing required forms or information

Contact Information:

Frequently Asked Questions

How long does Blue Cross Blue Shield prior authorization take in Washington? Standard PA review takes up to 15 business days. Expedited review for urgent cases is completed within 24-72 hours.

What if Evrysdi isn't on my Blue Cross Blue Shield formulary? You can request a formulary exception with supporting documentation from your specialist. This follows the same appeal process as a PA denial.

Can I get expedited review if my child has SMA Type I? Yes, severe or rapidly progressive SMA typically qualifies for expedited review due to the urgent nature of the condition.

Does step therapy apply if I've tried other SMA treatments outside Washington? Prior treatment history from any location should be documented and considered. Provide complete records of previous therapies and outcomes.

What happens if the external review upholds the denial? The external review decision is final for the insurance process, but you may still contact the OIC for guidance or consider legal consultation.

How much does Evrysdi cost without insurance? List price can approach $340,000 annually. The manufacturer's co-pay program and starter program help bridge coverage gaps.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for specific coverage decisions. For personalized assistance with insurance appeals and coverage strategies, consider consulting with Counterforce Health, which specializes in turning insurance denials into successful approvals through targeted, evidence-based appeals.

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