How to Get Evrysdi (Risdiplam) Covered by Cigna in California: Complete Prior Authorization and Appeals Guide
Answer Box: Getting Evrysdi Covered by Cigna in California
Yes, Cigna covers Evrysdi (risdiplam) with prior authorization. You need genetic confirmation of SMA (SMN1 mutations), baseline motor assessment scores, and prescription by a neuromuscular specialist. Fastest path: Have your neurologist submit the completed Cigna Evrysdi PA form with genetic test results and motor function scores via CoverMyMeds or fax (855-840-1678). Standard approval takes 72 hours. If denied, California's Independent Medical Review (IMR) overturns 55-73% of specialty drug denials. Start today: Call Cigna at the number on your insurance card to confirm your specialty drug benefits and download the PA form.
Table of Contents
- How to Use This Guide
- Eligibility Quick Check
- If You're Likely Eligible
- If You're Possibly Eligible
- If You're Not Yet Eligible
- If Your Request Gets Denied
- California Appeals Process
- Common Denial Reasons & Fixes
- Costs & Patient Support
- FAQ
- Sources & Further Reading
How to Use This Guide
This guide helps patients and families navigate Cigna's prior authorization process for Evrysdi (risdiplam) in California. We'll walk through eligibility requirements, document checklists, submission steps, and California's powerful appeal options if you're initially denied.
Evrysdi is an oral medication for spinal muscular atrophy (SMA) that costs approximately $340,000 annually, making prior authorization nearly universal. Counterforce Health specializes in turning insurance denials into evidence-backed appeals for complex medications like Evrysdi, helping patients navigate the documentation requirements and appeal processes that can feel overwhelming when you're already managing a serious condition.
Eligibility Quick Check
Answer these questions to determine your approval likelihood:
✓ Diagnosis Confirmed?
- Genetic test showing biallelic SMN1 pathogenic variants (homozygous deletion or compound heterozygous mutations)
- SMN2 copy number documented (typically 2-3 copies, or 4 copies with objective SMA signs)
✓ Clinical Documentation?
- Recent baseline motor assessment using validated scales (CHOP INTEND for infants, HFMSE/RULM/WHO milestones for older patients)
- Patient is at least 2 months old
- Current weight documented for dosing calculations
✓ Specialist Involvement?
- Prescription from neuromuscular specialist or neurologist experienced in SMA care
✓ Treatment History Clear?
- No prior Zolgensma (onasemnogene abeparvovec) - this is an absolute exclusion per Cigna's policy
- If switching from Spinraza (nusinersen), it must be discontinued
✓ For Females of Reproductive Age?
- Negative pregnancy test
- Effective contraception plan during treatment and 1 month post-discontinuation
If You're Likely Eligible
Document Checklist Before Submission:
| Required Document | What to Include | Where to Get It |
|---|---|---|
| Cigna Evrysdi PA Form | Completed by prescriber | CignaforHCP.com or CoverMyMeds |
| Genetic Test Report | CLIA-certified SMN1 mutation analysis, SMN2 copy number | Original testing lab |
| Neurologist Notes | SMA confirmation, motor scores, treatment rationale, monitoring plan | Specialist's office |
| Motor Assessment | Recent CHOP INTEND, HFMSE, RULM, or WHO milestone scores | Clinic visit notes |
| Weight Documentation | Current weight in kg for dosing | Recent clinic visit |
| Pregnancy Test (if applicable) | Negative result within appropriate timeframe | Lab or clinic |
Step-by-Step Submission Process:
- Verify Benefits (Patient): Call Cigna customer service (number on insurance card) to confirm specialty drug coverage, deductible status, and preferred specialty pharmacy
- Gather Documents (Clinic): Collect all items from checklist above
- Complete PA Form (Prescriber): Fill out Cigna Evrysdi form with clinical rationale
- Submit Request (Clinic): Use CoverMyMeds portal, fax to 855-840-1678, or submit through SureScripts
- Get Confirmation (Clinic): Obtain confirmation number and follow up within 72 hours
- Coordinate Pharmacy (Patient): Work with Accredo or designated specialty pharmacy once approved
- Track Timeline (Both): Standard review takes 72 hours; expedited review available for urgent cases (24 hours)
Tip: Submit Tuesday-Thursday for fastest processing, as weekend submissions may experience delays.
If You're Possibly Eligible
Missing pieces? Here's what to request:
- Genetic Testing: If you don't have SMN1/SMN2 results, ask your neurologist to order comprehensive SMA genetic panel from a CLIA-certified lab
- Motor Assessment: Schedule evaluation using age-appropriate validated scales - these provide objective baseline measurements Cigna requires
- Specialist Referral: If currently seeing a general neurologist, request referral to neuromuscular specialist familiar with SMA treatments
- Treatment History: Gather records of any prior SMA therapies, including reasons for discontinuation or contraindications
Timeline to Re-apply: Once you have missing documentation, the PA process takes 72 hours for standard review. Don't wait - gather these pieces proactively.
If You're Not Yet Eligible
Common scenarios and alternatives:
- Prior Zolgensma Treatment: Unfortunately, Cigna excludes Evrysdi for patients who've received Zolgensma. Discuss continued supportive care with your team
- Age Under 2 Months: Wait until patient reaches 2 months, then submit with all required documentation
- Incomplete Genetic Testing: Some patients have partial results - ensure comprehensive SMN1 deletion/duplication analysis is complete
Prepare for Exception Requests: Even with exclusions, you can request a formulary exception through Cigna's process if clinical circumstances warrant consideration.
If Your Request Gets Denied
Don't give up - California has excellent appeal options with high success rates for specialty drugs.
Immediate Steps:
- Request Denial Details: Get written explanation of specific denial reasons
- Gather Additional Evidence: Work with your neurologist to address cited gaps
- Consider Peer-to-Peer: Request physician-to-physician discussion with Cigna medical director
- Prepare Internal Appeal: Submit within 180 days with strengthened documentation
California's Unique Advantage: The state's Independent Medical Review (IMR) system overturns 55-73% of specialty drug denials, particularly for rare diseases like SMA with strong clinical evidence.
California Appeals Process
California offers robust patient protections through two regulatory agencies:
Department of Managed Health Care (DMHC) - Most Plans:
- Covers HMOs and most PPO plans
- Free Independent Medical Review after internal appeal
- File online or call 888-466-2219
- Timeline: 45 days standard, 72 hours expedited
- Binding decision - plan must comply if overturned
California Department of Insurance (CDI) - Some PPOs:
- Similar external review process
- Call 800-927-4357 for guidance
- Same timeline and binding decisions
Appeals Timeline:
| Step | Timeline | Action Required |
|---|---|---|
| Internal Appeal | 30-60 days | Submit to Cigna with additional evidence |
| IMR Application | Within 6 months of final denial | File with DMHC/CDI |
| IMR Decision | 45 days (standard) / 72 hours (expedited) | Independent physician review |
| Implementation | Immediate if overturned | Plan must authorize coverage |
Note: Counterforce Health helps families prepare evidence-backed appeals that address the specific clinical criteria California's independent reviewers evaluate, significantly improving success rates for complex cases like SMA treatments.
Common Denial Reasons & Fixes
| Denial Reason | How to Fix | Required Documentation |
|---|---|---|
| Missing genetic confirmation | Submit CLIA-certified SMN1 test | Complete genetic report with SMN1/SMN2 analysis |
| Incomplete motor assessment | Provide validated scale scores | CHOP INTEND, HFMSE, RULM, or WHO milestone documentation |
| Prior Zolgensma treatment | File formulary exception | Clinical rationale for unique circumstances |
| No specialist involvement | Get neuromuscular specialist | Referral and prescription from qualified specialist |
| Dosing/weight documentation gaps | Update clinical records | Recent weight measurement and dosing calculations |
| Duplicative therapy concerns | Clarify treatment history | Documentation of Spinraza discontinuation if applicable |
Costs & Patient Support
Manufacturer Support:
- Genentech offers patient assistance programs
- Copay assistance may be available for eligible patients
- Contact Genentech Access Solutions for current programs
California Resources:
- Medi-Cal may cover Evrysdi for eligible patients
- California Children's Services for pediatric patients
- Health Consumer Alliance provides free assistance with appeals
Specialty Pharmacy:
- Most Cigna plans use Accredo for Evrysdi
- Coordinate benefits verification before first shipment
- Track prior authorization status through pharmacy portal
FAQ
How long does Cigna prior authorization take for Evrysdi in California? Standard review takes 72 hours. Expedited review for urgent cases takes 24 hours. Submit Tuesday-Thursday for fastest processing.
What if Evrysdi is non-formulary on my Cigna plan? You can request a formulary exception with clinical justification. The process takes 72 hours and requires physician documentation of medical necessity.
Can I request an expedited appeal in California? Yes, both Cigna and California's IMR system offer expedited review (24-72 hours) for urgent medical situations where delays could harm health.
Does step therapy apply if I tried treatments outside California? Treatment history from any location counts. Provide documentation of prior therapy failures or contraindications regardless of where they occurred.
What happens if my internal appeal is denied? California residents can request Independent Medical Review (IMR) through DMHC or CDI. This external review overturns 55-73% of specialty drug denials.
How much will Evrysdi cost with Cigna coverage? Costs depend on your plan's specialty tier copay or coinsurance. Call Cigna to verify your specific out-of-pocket costs before starting treatment.
Can I switch from Spinraza to Evrysdi? Yes, but you must discontinue Spinraza first. Provide documentation of the switch rationale and timeline to avoid duplicative therapy denials.
What if I'm pregnant or planning pregnancy? Evrysdi requires effective contraception. Discuss family planning with your neurologist and document contraception plans in your PA submission.
Sources & Further Reading
- Cigna Evrysdi Prior Authorization Policy (PDF)
- Cigna Evrysdi PA Form (PDF)
- California DMHC Independent Medical Review
- Cigna Formulary Exception Process (PDF)
- SMA Treatment Guidelines - Neurology
- FDA Evrysdi Prescribing Information
Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult your healthcare provider and insurance plan for personalized guidance. For assistance with complex appeals, consider consulting with patient advocacy organizations or services like Counterforce Health that specialize in insurance coverage for specialty medications.
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