By Counterforce Health Team in Evrysdi (risdiplam) —

How to Get Evrysdi (Risdiplam) Covered by Cigna in Georgia: Prior Authorization, Appeals & Coding Guide

Answer Box: Getting Evrysdi Covered by Cigna in Georgia

Eligibility: Patients ≥2 months with genetically confirmed 5q-SMA can get Evrysdi covered by Cigna with proper documentation. Fastest path: Submit prior authorization with genetic test results, baseline motor assessment (CHOP-INTEND/HFMSE), and specialist letter. First step today: Contact your neurologist to request the Cigna Evrysdi PA form and gather required documentation. If denied, you have 180 days for internal appeal and 4 months for federal external review through HHS/MAXIMUS.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Timeline
Prior Authorization Required for all Evrysdi prescriptions Cigna provider portal or Express Scripts 5-14 business days
Genetic Testing SMN1 deletion/mutation confirmation CLIA-certified lab report Must be on file
Motor Assessment CHOP-INTEND, HFMSE, or RULM baseline Performed by neurologist Within 90 days
Specialist Prescriber Neurologist or pediatric neurologist Provider credentialing Required
Age Requirement ≥2 months per FDA labeling Birth certificate/medical record Documented

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Obtain PA Form

Who: Patient or clinic staff
Action: Call Cigna member services to confirm Evrysdi is covered under the specialty pharmacy benefit
Timeline: Same day
Tip: Ask specifically about Express Scripts management and any formulary restrictions

2. Gather Required Documentation

Who: Clinic team
Documents needed:

  • Genetic test report showing SMN1 deletion/mutation
  • SMN2 copy number results
  • Recent clinic notes with SMA type documentation
  • Baseline motor function assessment (CHOP-INTEND, HFMSE, RULM)
  • Current weight and age documentation Timeline: 1-2 weeks if tests are pending

3. Complete Prior Authorization

Who: Prescribing neurologist
Action: Submit PA through Cigna provider portal or Express Scripts
Required fields:

  • ICD-10 code (G12.0 for Type 1, G12.1 for Types 2-4)
  • Weight-based dosing calculation
  • Justification for Evrysdi vs. alternatives Timeline: Submit within 30 days of clinic visit

4. Track and Follow Up

Who: Clinic staff or patient
Action: Monitor PA status through provider portal
Timeline: Decision typically within 5-14 business days
Next steps: If approved, coordinate with specialty pharmacy; if denied, proceed to appeals

ICD-10 Coding and Documentation

Primary Diagnosis Codes for SMA

The correct ICD-10-CM code depends on the specific SMA type:

  • G12.0: Infantile spinal muscular atrophy, type I (Werdnig-Hoffmann)
  • G12.1: Other inherited spinal muscular atrophy (covers Types 2, 3, and 4)
  • G12.8: Other spinal muscular atrophies and related syndromes
  • G12.9: Spinal muscular atrophy, unspecified

Supporting Documentation Requirements

Genetic Confirmation: Medical records must include genetic test results showing:

  • Biallelic SMN1 deletion or pathogenic variants
  • SMN2 copy number (typically 2-4 copies)
  • Lab report from CLIA-certified facility

Clinical Documentation: Include in medical records:

  • SMA type classification based on age of onset and motor milestones
  • Current functional status (sitting, standing, walking ability)
  • Respiratory support requirements
  • Nutritional status and swallowing function

Product Coding: NDC, HCPCS, and Billing

NDC Codes for Evrysdi

Primary NDCs:

  • 50242-175-07: 60 mg/80 mL oral solution (most common for weight-based dosing)
  • 50242-215-01: 5 mg tablets (for patients ≥20 kg)

HCPCS Coding for Medical Benefit

When billed under the medical benefit (rare), use:

  • J8499: Prescription drug, oral, non-chemotherapeutic, NOS
  • Include "Evrysdi (risdiplam)" in Box 19/remarks
  • Report units based on daily mg dose × days supplied

Weight-Based Dosing Calculations

Age Group Daily Dose Calculation Method
< 2 months 0.15 mg/kg Weight (kg) × 0.15
2 months to < 2 years 0.20 mg/kg Weight (kg) × 0.20
≥ 2 years and < 20 kg 0.25 mg/kg Weight (kg) × 0.25
≥ 2 years and ≥ 20 kg 5 mg flat dose Fixed dose, no calculation

Volume Conversion: Daily dose (mg) ÷ 0.75 mg/mL = daily volume (mL)

Clean Prior Authorization Anatomy

A complete Evrysdi PA submission should include:

Section 1: Patient Information

  • Full name, DOB, Cigna member ID
  • Current weight in kilograms with date
  • Age in months (for pediatric patients)

Section 2: Clinical Justification

  • Diagnosis: ICD-10 code with SMA type specification
  • Genetic confirmation: "Patient has genetically confirmed 5q-SMA with biallelic SMN1 deletion and [X] SMN2 copies"
  • Motor status: Baseline assessment score and date
  • Medical necessity: "Evrysdi is FDA-approved for this indication and medically necessary to prevent irreversible motor neuron loss"

Section 3: Dosing and Administration

  • Weight-based dose calculation showing work
  • Route of administration (oral solution or tablet)
  • Frequency (once daily)
  • Duration of therapy request
Tip: Include a brief statement about why alternatives (Spinraza, Zolgensma) are not appropriate for this patient.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Genetic testing not confirmed" Submit complete lab report CLIA-certified SMN1/SMN2 test results
"Missing baseline assessment" Provide motor function scores CHOP-INTEND, HFMSE, or RULM with date
"Step therapy required" Request exception with medical justification Letter explaining contraindications to alternatives
"Not medically necessary" Submit peer-reviewed evidence FDA labeling, clinical guidelines, specialist letter
"Dosing documentation incomplete" Provide weight-based calculations Current weight, age, dose calculation worksheet

Appeals Playbook for Cigna in Georgia

Internal Appeal Process

Timeline: Must file within 180 days of denial
Method: Submit through Cigna provider portal or member services
Required documents:

  • Original denial letter
  • Medical necessity letter from neurologist
  • Updated clinical documentation
  • Peer-reviewed literature supporting Evrysdi use

Expedited Appeals: Available if delay would "seriously jeopardize life or ability to regain function"

External Review (Federal Process)

Georgia uses the federal external review process administered by HHS/MAXIMUS.

Deadline: 4 months from final internal appeal decision
How to file:

  • Online: externalappeal.cms.gov
  • Phone: 1-888-866-6205
  • Fax: 1-888-866-6190

Timeline:

  • Standard review: 45 days maximum
  • Expedited review: 72 hours maximum
Note: External review decisions are binding on Cigna under federal law.

Georgia Consumer Protections

If external review fails, file a complaint with the Georgia Office of Insurance and Safety Fire Commissioner. Include all denial letters, medical records, and external review decisions.

Costs & Patient Assistance Programs

Manufacturer Support: Genentech offers copay assistance and patient support programs through their Access Solutions program.

Foundation Grants: Organizations like the Muscular Dystrophy Association may provide financial assistance for SMA treatments.

Cigna Coverage: Most commercial plans cover Evrysdi as a specialty medication with typical copays ranging from $50-$100 per month after meeting deductibles.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed submissions. Our platform analyzes denial letters and plan policies to identify the specific reasons for denial, then generates point-by-point rebuttals aligned with each payer's requirements. For SMA medications like Evrysdi, we pull together the right clinical evidence—FDA labeling, specialty guidelines, and peer-reviewed studies—while ensuring all procedural requirements are met for both initial submissions and appeals.

FAQ

Q: How long does Cigna prior authorization take for Evrysdi?
A: Standard PA decisions are typically made within 5-14 business days. Expedited requests (for urgent medical situations) are decided within 72 hours.

Q: What if Evrysdi is not on Cigna's formulary?
A: You can request a formulary exception by providing medical justification for why covered alternatives are inappropriate or contraindicated.

Q: Can I appeal if I live in Georgia but have a Cigna plan from another state?
A: Appeal rights depend on where your plan is regulated, not where you live. Check your EOB for the specific appeal process and timelines.

Q: Does step therapy apply to Evrysdi?
A: Some Cigna plans require trying Spinraza first. You can request a step therapy exception if your doctor provides medical justification.

Q: What counts as an urgent situation for expedited appeals?
A: Your doctor must certify that waiting for a standard appeal timeline would "seriously jeopardize life or ability to regain or maintain maximum function."

Q: How much does Evrysdi cost without insurance?
A: List price is approximately $340,000 annually for weight-based dosing, though actual costs vary by patient weight and age.

When navigating coverage challenges, remember that Counterforce Health specializes in turning denials into approvals through systematic, evidence-based appeals that align with each payer's specific requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and verify current insurance policies and procedures with your specific plan. Coverage policies and appeal processes may change; confirm current requirements with Cigna and Georgia regulatory authorities.

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