How to Get Evrysdi (Risdiplam) Covered by Cigna in New York: Complete Prior Authorization and Appeals Guide
Answer Box: Getting Evrysdi Covered by Cigna in New York
Eligibility: Cigna covers Evrysdi (risdiplam) for spinal muscular atrophy with prior authorization requiring genetic confirmation (SMN1 gene variants), baseline motor function assessment, and neurologist prescription. Fastest approval path: Submit complete PA packet through CoverMyMeds with genetic test results, motor function scores (MFM-32 or RULM), and weight-based dosing calculation. First step today: Contact your neurologist to request genetic testing if not already completed and schedule motor function assessment. If denied, New York residents can appeal through Cigna (180 days) then external review via NY Department of Financial Services (4 months).
Table of Contents
- Coverage at a Glance
- Step-by-Step: Fastest Path to Approval
- Common Denial Reasons & How to Fix Them
- Appeals Playbook for New York
- Medical Necessity Letter Checklist
- Cost Savings and Patient Support
- When to Escalate in New York
- Frequently Asked Questions
Coverage at a Glance
| Requirement | What It Means | Where to Find It | Source |
|---|---|---|---|
| Prior Authorization | Required for all Evrysdi prescriptions | Cigna formulary, Express Scripts | Cigna Pharmacy Policies |
| Genetic Testing | SMN1 gene variants confirmed by CLIA lab | Neurologist or genetic counselor | Cigna Genetic Testing Policy |
| Motor Assessment | MFM-32, RULM, HFMSE, or BSID-III scores | Neurologist or physical therapist | Clinical Guidelines |
| Prescriber | Board-certified neurologist required | Provider directory | Cigna Provider Policies |
| Response Time | 72 hours standard, 24 hours urgent | PA submission confirmation | Cigna Appeals Process |
Step-by-Step: Fastest Path to Approval
1. Confirm SMA Diagnosis and Genetic Testing
Who does it: Your neurologist
What's needed: CLIA-certified genetic test showing SMN1 gene variants and SMN2 copy number
Timeline: 1-2 weeks for results
Submit via: Include lab report in PA packet
Tip: If genetic testing was done years ago, request a copy from the original lab. Cigna accepts historical results if they meet current standards.
2. Complete Baseline Motor Function Assessment
Who does it: Neurologist or qualified physical therapist
What's needed: One of these validated assessments: MFM-32, RULM, HFMSE, or BSID-III
Timeline: Single appointment, results available immediately
Submit via: Include assessment scores and interpretation in PA packet
3. Calculate Weight-Based Dosing
Who does it: Prescribing neurologist
What's needed: Current weight and age-appropriate dose calculation
Dosing: 0.15 mg/kg (under 2 months), 0.20 mg/kg (2 months to 2 years), 0.25 mg/kg (over 2 years, under 20 kg), or 5 mg fixed dose (over 20 kg)
Submit via: Include dosing rationale on prescription
4. Gather Required Documentation
Who does it: Patient or caregiver coordinates with clinic
What's needed:
- Genetic test results (SMN1/SMN2)
- Motor function assessment scores
- Neurologist prescription with ICD-10 codes (G12.0, G12.1, or G12.9)
- Prior treatment history (if applicable)
- Insurance card and member ID
5. Submit Prior Authorization
Who does it: Neurologist's office
Submit via: CoverMyMeds portal or Cigna provider portal
Timeline: Submit within 1-2 business days of gathering documents
Confirmation: Request submission confirmation number
6. Track Response and Follow Up
Who does it: Patient or clinic staff
Timeline: Check status after 48 hours via Cigna member portal
Next step: If approved, coordinate with specialty pharmacy; if denied, initiate appeal within 180 days
7. Coordinate Specialty Pharmacy Fulfillment
Who does it: Patient with Accredo or assigned specialty pharmacy
Timeline: 3-5 business days for first shipment after approval
Follow-up: Schedule regular refills and monitoring appointments
Common Denial Reasons & How to Fix Them
| Denial Reason | How to Overturn | Required Documents |
|---|---|---|
| Missing genetic confirmation | Submit CLIA-certified genetic test results | SMN1/SMN2 analysis report |
| Incomplete motor assessment | Provide validated assessment scores | MFM-32, RULM, HFMSE, or BSID-III results |
| Incorrect dosing calculation | Recalculate based on current weight/age | Updated prescription with dosing rationale |
| Non-specialist prescriber | Transfer prescription to neurologist | Board certification verification |
| Duplicative therapy concerns | Document why Evrysdi is preferred over Spinraza/Zolgensma | Comparative clinical rationale |
| "Not medically necessary" | Submit comprehensive medical necessity letter | Complete clinical history and guidelines |
Appeals Playbook for New York
Internal Appeals with Cigna
Level 1 Appeal
- Deadline: 180 days from denial date
- Timeline: 30 days for decision (72 hours if expedited)
- How to file: Cigna member portal or call member services
- Required: Denial letter, medical records, physician statement
Level 2 Appeal (Medical Director Review)
- Deadline: 60 days after Level 1 denial
- Timeline: 30 days for decision
- Process: Automatic peer-to-peer review available
- Advantage: Direct physician-to-physician discussion of medical necessity
External Appeal Through New York DFS
If Cigna denies your internal appeals, New York residents have strong external review rights:
Filing Requirements
- Deadline: 4 months after final Cigna denial
- Fee: $25 (waived for Medicaid or financial hardship)
- How to file: NY DFS External Appeal Portal
- Timeline: 30 days standard, 72 hours expedited, 24 hours for urgent drug requests
Required Documents
- Completed NY External Appeal Application
- Final adverse determination from Cigna
- All medical records supporting medical necessity
- Physician attestation letter
Note: External review decisions are legally binding on Cigna. New York's external appeal success rate for well-documented specialty drug cases is approximately 50-70%.
Free Help Available Contact Community Health Advocates at 888-614-5400 for free assistance with your appeal. They can help you navigate the process and access their searchable database of successful external appeals.
Medical Necessity Letter Checklist
When appealing a denial, your neurologist should include these elements in the medical necessity letter:
Clinical Foundation
- Confirmed SMA diagnosis with genetic testing results (SMN1 variants, SMN2 copy number)
- Current functional status using validated motor assessments
- Disease progression and impact on daily activities
- Treatment goals (maintain function, slow progression, improve quality of life)
Treatment Rationale
- Why Evrysdi specifically: Oral administration, at-home dosing, CNS penetration
- Comparison to alternatives: Why not Spinraza (intrathecal) or Zolgensma (age/weight limits)
- Dosing appropriateness: Weight-based calculation and administration plan
- Monitoring plan: Regular assessments and safety monitoring
Supporting Evidence
Include references to:
- FDA prescribing information
- SMA treatment guidelines from neuromuscular societies
- Clinical trial data (FIREFISH, SUNFISH studies)
- Peer-reviewed literature supporting oral SMN2 splicing modifiers
Cost Savings and Patient Support
Genentech Patient Support
- Copay assistance: Up to $15,000 annually for eligible patients
- Patient Access Program: Support for uninsured or underinsured patients
- Contact: Visit Evrysdi.com or call patient support
Foundation Grants
- Cure SMA: Emergency financial assistance for SMA families
- HealthWell Foundation: Copay assistance for rare disease medications
- Patient Access Network: Specialty drug copay support
New York State Programs
- Medicaid: Covers Evrysdi with prior authorization
- Essential Plan: Low-cost coverage for moderate-income families
- EPIC: Prescription assistance for seniors
Counterforce Health helps patients navigate insurance denials by turning complex prior authorization requirements into targeted, evidence-backed appeals. Their platform analyzes denial letters and payer policies to draft point-by-point rebuttals that align with each plan's specific criteria, significantly improving approval rates for specialty medications like Evrysdi.
When to Escalate in New York
If standard appeals aren't successful, New York residents have additional protections:
File a Complaint with NY DFS
- When: If Cigna violates appeal timelines or procedures
- How: DFS Consumer Complaint Portal
- Include: Timeline of appeals, correspondence, policy violations
Contact State Representatives
- Assembly Health Committee: Can intervene in complex cases
- Insurance Superintendent: Oversees insurer compliance with state laws
Legal Resources
- New York Legal Aid: Free legal assistance for low-income patients
- Disability Rights New York: Advocacy for patients with disabilities
Frequently Asked Questions
How long does Cigna prior authorization take for Evrysdi in New York? Standard PA decisions are issued within 72 hours. Urgent requests (when delay could seriously jeopardize health) receive decisions within 24 hours.
What if Evrysdi is not on Cigna's formulary? You can request a formulary exception by submitting a medical necessity letter explaining why covered alternatives are inappropriate. The process is the same as standard PA but may take longer.
Can I request an expedited appeal? Yes, if delaying treatment could seriously jeopardize your health or ability to regain maximum function. Your neurologist must document the urgency in writing.
Does step therapy apply if I've tried other SMA treatments? Document all prior treatments (Spinraza, other therapies) and their outcomes. Failed prior therapy often supports medical necessity for Evrysdi.
What happens if my child's weight changes significantly? Evrysdi dosing is weight-based, so dose adjustments require new PA approval. Submit updated weight and dosing calculation to avoid coverage gaps.
How do I find a neurologist who accepts Cigna? Use the Cigna provider directory to find in-network neurologists. Specify "pediatric neurologist" if treating a child.
What if I move to another state while on Evrysdi? Coverage may change based on state regulations and plan variations. Contact Cigna member services before moving to understand any impacts.
Can I appeal if Cigna approves a lower dose than prescribed? Yes, submit a quantity limit exception with clinical justification for the higher dose. Include weight-based calculations and FDA dosing guidelines.
From our advocates: We've seen families succeed by preparing comprehensive PA packets upfront rather than submitting minimal documentation and appealing later. One family gathered genetic testing, motor assessments, and specialist letters before their first submission—they received approval within 48 hours, avoiding months of delays while their child's condition progressed.
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal procedures may change. Always verify current requirements with Cigna and consult with your healthcare providers about appropriate treatment decisions.
For additional help with insurance appeals in New York, contact Community Health Advocates at 888-614-5400 or visit the NY Department of Financial Services for official appeal forms and procedures.
Sources & Further Reading
- Cigna Genetic Testing Policy MM-0052
- Cigna Appeals and Disputes Process
- NY DFS External Appeal Application
- Evrysdi FDA Prescribing Information
- Community Health Advocates Appeal Database
- Cigna Member Appeals Guide
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