By Counterforce Health Team in Evrysdi (risdiplam) —

How to Get Evrysdi (Risdiplam) Covered by Cigna in Texas: Complete PA Guide and Appeal Process

Answer Box: Getting Evrysdi (Risdiplam) Covered by Cigna in Texas

Cigna requires prior authorization for Evrysdi (risdiplam) with genetic testing, motor assessment, and specialist involvement. Submit electronically via CoverMyMeds or Accredo's portal for fastest approval (72 hours). If denied, file internal appeal within 180 days, then Texas external review within 4 months. Start today: Gather genetic test results showing bi-allelic SMN1 mutations, baseline motor scores (CHOP INTEND/HFMSE), and confirm your neurologist will complete the PA.

Table of Contents

  1. Start Here: Verify Your Plan and Coverage
  2. Prior Authorization Requirements
  3. Forms and Submission Portals
  4. Specialty Pharmacy Setup
  5. Common Denial Reasons and Solutions
  6. Appeals Process in Texas
  7. Support Contacts
  8. Cost Assistance Options
  9. FAQ

Start Here: Verify Your Plan and Coverage

Before beginning the prior authorization process, confirm your Cigna plan details and Evrysdi's coverage status:

Check Your Plan Type:

  • Commercial/Employer Plans: Follow Texas state-regulated appeal process
  • Medicare Advantage: Use federal Medicare appeal rules
  • Self-funded ERISA Plans: Federal appeals process applies

Verify Coverage:

  1. Log into myCigna.com or call member services (number on your ID card)
  2. Confirm Evrysdi requires prior authorization
  3. Check if specialty pharmacy (Accredo) is required
  4. Review your formulary tier and any step therapy requirements
Note: Texas has strong patient appeal rights for state-regulated plans, including expedited external review through the Texas Department of Insurance.

Prior Authorization Requirements

Cigna's clinical policy for Evrysdi requires comprehensive documentation for approval:

Core Coverage Criteria

Requirement Documentation Needed Where to Find It
Genetic Testing Bi-allelic pathogenic variants in SMN1 gene Laboratory genetic test report
Motor Assessment Baseline scores using approved scales CHOP INTEND, HFMSE, HINE Section 2, RULM, or WHO milestones
SMN2 Copy Number Documentation of SMN2 copies and SMA type Genetic testing report
Specialist Involvement Prescription by neuromuscular specialist Provider credentials and consultation notes
Exclusion Criteria No complete paralysis or permanent ventilation Clinical assessment documentation

Accepted Motor Function Scales

Cigna accepts any of these standardized assessments:

  • CHOP INTEND (Children's Hospital of Philadelphia Infant Test)
  • HFMSE (Expanded Hammersmith Functional Motor Scale)
  • CHOP-ATEND (Adult Test of Neuromuscular Disorders)
  • HINE Section 2 (Motor milestones)
  • RULM (Revised Upper Limb Module)
  • WHO Motor Milestone Scale
Clinician Corner: Include baseline scores with interpretation showing findings consistent with SMA. For continuation requests, document improvement or stabilization compared to pre-treatment baseline.

Forms and Submission Portals

Electronic Submission (Recommended - Fastest Approval)

Primary Options:

  1. CoverMyMeds: covermymeds.com/epa/express-scripts
    • Free portal with real-time status tracking
    • Integrated with Cigna/Express Scripts systems
    • Upload supporting documents directly
  2. Accredo iAssist: myaccredopatients.com
    • For patients using Accredo specialty pharmacy
    • Complete PA with new referral submission
    • Direct connection to Cigna specialty benefits
  3. EviCore by Evernorth: evicore.com
    • Select "Pharmacy Drug (Express Scripts Coverage)"
    • Handles complex specialty drug PAs

Backup Submission Methods

If electronic submission unavailable:

  • Phone PA: 1-800-882-4462 (mark urgent if standard timeline risks health)
  • Fax: Use generic form to (855) 840-1678 with required documentation

Required Documentation Checklist

  • Completed PA form with patient/provider information
  • Genetic test report showing SMN1 mutations and SMN2 copy number
  • Baseline motor assessment scores and interpretation
  • SMA diagnosis with ICD-10 code (G12.x)
  • Previous therapy trials and outcomes (if applicable)
  • Weight-based dosing calculation
  • Specialist consultation notes or credentials

Specialty Pharmacy Setup

Cigna typically requires Evrysdi to be dispensed through Accredo specialty pharmacy:

Accredo Onboarding Steps

  1. Provider Enrollment: Call Accredo Physician Service Center at 844-516-3319
  2. Patient Registration: 1-800-803-2523 (7am-10pm CT Mon-Fri)
  3. Insurance Verification: Accredo verifies Cigna benefits and PA status
  4. Home Delivery Setup: Coordinate shipping and storage instructions

Transfer from Another Pharmacy

If currently using a different specialty pharmacy:

  • Contact Accredo with current pharmacy information
  • Request prescription transfer after PA approval
  • Coordinate timing to avoid therapy gaps
Tip: Accredo provides 24/7 pharmacist and nurse support at no additional cost. They'll also coordinate with your clinical team for ongoing monitoring.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Missing genetic testing Submit complete genetic report Lab report with SMN1 mutations and SMN2 copies
Inadequate motor assessment Provide standardized scale scores CHOP INTEND, HFMSE, or other approved assessment
Concurrent therapy concern Document discontinuation of other SMA drugs Provider letter confirming no concurrent Spinraza/Zolgensma
Non-specialist prescriber Obtain specialist consultation Neurologist consultation notes or referral
Dosing documentation gaps Submit weight-based calculations Current weight and dosing rationale

Medical Necessity Letter Template

Your neurologist should include:

  • Problem: SMA diagnosis with genetic confirmation
  • Prior treatments: Previous therapies tried and outcomes
  • Clinical rationale: Why Evrysdi is medically necessary
  • Guideline support: Reference to FDA labeling and SMA treatment guidelines
  • Monitoring plan: Ongoing assessment schedule

Appeals Process in Texas

If your initial PA is denied, Texas provides a structured appeals process:

Internal Appeals (Required First Step)

Timeline: File within 180 days of denial notice Review Period: 30-60 days (72 hours for expedited) Submission: Written appeal to address on denial letter

Required Documents:

  • Original denial letter
  • New supporting evidence
  • Provider letter of medical necessity
  • Updated clinical information

Texas External Review

Eligibility: After exhausting internal appeals Timeline: Request within 4 months of final internal denial Process: Independent Review Organization (IRO) through Texas Department of Insurance Cost: Free to patient (insurer pays)

Contact Information:

Important: Self-funded employer plans (ERISA) follow federal appeals rules, not Texas state process. Check your plan documents or call member services to confirm.

Expedited Appeals

Request expedited review if:

  • Standard timeline would seriously jeopardize health
  • SMA symptoms are rapidly progressing
  • Current therapy has failed or caused adverse reactions

Timeline: 72 hours for internal; 5 days for external review

Support Contacts

Member Services

  • Cigna Member Services: Number on your ID card
  • Accredo Member Services: 1-800-803-2523
  • Cigna Specialty Care Manager: 1-877-505-3681

Provider Services

  • Accredo Physician Service Center: 844-516-3319
  • Prior Authorization: 1-800-882-4462
  • Express Scripts: 1-877-860-0982

Texas Consumer Assistance

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742
  • Disability Rights Texas: disabilityrightstx.org

Cost Assistance Options

Manufacturer Support

  • Evrysdi Patient Support Program: evrysdi.com/financial-support
  • Copay assistance for eligible patients
  • Case management support for insurance navigation

Foundation Grants

Research patient assistance programs through:

  • National Organization for Rare Disorders (NORD)
  • HealthWell Foundation
  • Patient Access Network Foundation
Note: Assistance availability varies by insurance type and income level. Contact programs directly for current eligibility criteria.

When navigating complex prior authorization requirements for specialty medications like Evrysdi, having expert support can make the difference between approval and denial. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by analyzing denial letters, identifying specific coverage criteria, and crafting evidence-backed responses that align with each payer's requirements.

FAQ

How long does Cigna PA take for Evrysdi in Texas? Electronic submissions typically receive decisions within 72 hours. Paper submissions may take 5-10 business days. Expedited reviews are completed within 24-48 hours for urgent cases.

What if Evrysdi is non-formulary on my Cigna plan? Request a formulary exception through your physician. Submit clinical justification showing formulary alternatives are ineffective or contraindicated for your specific SMA type.

Can I request an expedited appeal in Texas? Yes. If standard timelines would jeopardize your health, request expedited internal appeals (72 hours) and external review (5 days) through Texas Department of Insurance.

Does step therapy apply to Evrysdi? Cigna may require documentation of previous SMA therapies. However, if no FDA-approved alternatives exist for your specific situation, step therapy requirements may be waived.

What happens if my appeal is denied? After exhausting internal appeals, you can request external review through Texas Department of Insurance. The IRO decision is binding on the insurer if they rule in your favor.

How do I transfer Evrysdi to Accredo specialty pharmacy? Contact Accredo at 1-800-803-2523 with your current pharmacy information. They'll coordinate the transfer and ensure no gaps in therapy once PA is approved.

Can I use Counterforce Health for my Evrysdi appeal? Counterforce Health specializes in turning insurance denials into targeted appeals for specialty medications. They can help analyze your denial and craft a response aligned to Cigna's specific coverage criteria.

What if my doctor isn't a neuromuscular specialist? Cigna requires specialist involvement. Your primary doctor can obtain a consultation from a neurologist or refer you to a neuromuscular specialist for Evrysdi prescription and ongoing management.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance regarding your situation.

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