By Counterforce Health Team in Evrysdi (risdiplam) —

How to Get Evrysdi (Risdiplam) Covered by Humana in California: Prior Authorization, Appeals, and Step Therapy Guide

Answer Box: Getting Evrysdi Covered by Humana in California

Evrysdi (risdiplam) requires prior authorization from Humana and is typically placed on a specialty drug tier with higher cost-sharing. To get approved: (1) Submit genetic confirmation of 5q SMA with SMN1 deletion, (2) Document baseline motor assessments and prior therapy history, (3) Use CenterWell Specialty Pharmacy for dispensing. If denied, you have 65 days to appeal and can request expedited review if medically urgent. California residents can escalate to Independent Medical Review (IMR) through DMHC after internal appeals.

First step today: Contact your prescriber to initiate prior authorization through Humana's provider portal with complete SMA genetic testing and clinical documentation.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Must be approved before dispensing Humana provider portal Humana policy
Formulary Tier Tier 5/6 specialty drug Humana drug finder Plan formulary
Step Therapy May require trial of preferred agents first Plan documents Payer policies
Specialty Pharmacy Must use CenterWell or approved network CenterWell enrollment Humana network
Genetic Testing SMN1 deletion confirmation required Lab reports Medical necessity
Appeal Deadline 65 days from denial notice Medicare appeals guide CMS regulations

Plan Types & Network Implications

Humana offers several plan types in California, each with different coverage rules for Evrysdi:

Medicare Advantage Plans: Most common Humana option in California. These plans bundle Part A, B, and often Part D prescription coverage. Evrysdi falls under Part D since it's an oral medication, requiring adherence to Medicare prescription drug benefit rules.

Medicare Part D Stand-Alone: If you have Original Medicare plus a separate Humana Part D plan, the same prior authorization and specialty pharmacy requirements apply.

Commercial Plans: Less common but available through some California employers. May have different prior authorization criteria and appeals processes compared to Medicare plans.

Note: Network restrictions are particularly important for specialty medications. Using out-of-network pharmacies can result in complete denial of coverage, not just higher cost-sharing.

Formulary Status & Tier Placement

Based on 2024 Humana formulary documents, Evrysdi is placed on Tier 5 or Tier 6 as a specialty medication. This placement means:

  • Higher cost-sharing: Typically 25-33% coinsurance rather than fixed copays
  • Specialty pharmacy requirement: Cannot be filled at regular retail pharmacies
  • Prior authorization mandatory: No exceptions for urgent fills without PA approval

The exact tier varies by specific plan design. Check your individual plan's comprehensive drug guide for precise cost-sharing amounts.

Alternative agents on Humana formularies include Spinraza (nusinersen) and Zolgensma (onasemnogene), but these also require prior authorization and have their own restrictions.

Prior Authorization Requirements

Humana's prior authorization for Evrysdi requires comprehensive documentation:

Medical Necessity Criteria

  1. Genetic Confirmation: Documented 5q spinal muscular atrophy with biallelic SMN1 gene mutations
  2. Clinical Assessment: Baseline motor function evaluation by neuromuscular specialist
  3. Age and Weight Documentation: Required for proper dosing calculations
  4. Prior Therapy History: Documentation of any previous SMA treatments and outcomes

Required Documentation

  • Genetic test results showing SMN1 deletion
  • SMN2 copy number analysis (recommended for prognosis)
  • Neurological examination findings
  • Motor milestone assessments
  • Previous treatment records (if switching from Spinraza or other agents)
  • Prescriber attestation of medical necessity

The prior authorization form must be completed by the prescribing physician and submitted through Humana's provider portal.

Step Therapy & Duplicative Therapy Rules

Humana enforces strict policies around SMA medications:

Duplicative Therapy Prohibition

Concurrent use of multiple SMA treatments is never approved. This means:

  • Cannot use Evrysdi with Spinraza simultaneously
  • Cannot use Evrysdi with Zolgensma simultaneously
  • Must document discontinuation of previous agent before starting new therapy

Step Therapy Requirements

While not always required as first-line, step therapy may apply when:

  • Switching between SMA medications
  • Previous therapy failure or intolerance must be documented
  • Clinical rationale for specific agent selection required
Critical Point: Patients who previously received Zolgensma (gene therapy) are generally ineligible for subsequent coverage of Evrysdi or Spinraza under most payer policies.

Exceptions Process

Step therapy exceptions may be granted for:

  • Documented contraindications to preferred agents
  • Previous adverse reactions or intolerance
  • Clinical factors favoring specific medication choice

Exception requests require detailed clinical justification and specialist support.

Specialty Pharmacy Requirements

Evrysdi must be dispensed through Humana's specialty pharmacy network:

CenterWell Specialty Pharmacy

Primary preferred partner: CenterWell Specialty Pharmacy (formerly Humana Specialty Pharmacy)

Patient enrollment process:

  1. Prescriber submits prescription and PA to CenterWell
  2. CenterWell contacts patient for enrollment and benefit verification
  3. Clinical pharmacist reviews dosing and administration
  4. Medication shipped directly to patient with clinical support

Network Requirements

  • In-network dispensing mandatory: Out-of-network specialty pharmacies typically result in complete coverage denial
  • Clinical monitoring: Specialty pharmacists provide ongoing support and monitoring
  • Coordination of care: Direct communication with prescribing physicians

Alternative network pharmacies may be available but require prior approval. Contact Humana member services to verify network status.

Cost-Share Dynamics

Understanding your out-of-pocket costs helps with financial planning:

Typical Cost Structure

  • Deductible: May apply before coverage begins (varies by plan)
  • Coinsurance: Usually 25-33% of drug cost for specialty tiers
  • Out-of-pocket maximum: Annual limit on total drug costs
  • Coverage gap: "Donut hole" may apply to Medicare Part D plans

Cost Estimation

With Evrysdi's list price around $340,000 annually, even a 25% coinsurance could result in substantial monthly costs. However, most plans have out-of-pocket maximums that cap annual spending.

Educational Note: These are general cost-sharing concepts. Your specific costs depend on your individual plan design and should be verified with Humana directly.

Submission Process

For Prescribers

  1. Complete prior authorization form with all required clinical documentation
  2. Submit through Humana provider portal or designated fax line
  3. Include supporting documentation: genetic tests, clinical notes, prior therapy records
  4. Specify CenterWell Specialty Pharmacy for dispensing

Timeline Expectations

  • Standard PA review: Up to 72 hours for initial determination
  • Expedited review: Available if delay would jeopardize patient health
  • Additional information requests: May extend timeline if documentation incomplete

Tracking Status

Providers can track PA status through the Humana portal. Patients should contact member services for updates.

Appeals Process in California

If your Evrysdi prior authorization is denied, California residents have robust appeal rights:

Internal Appeals (Redetermination)

Timeline: 65 days from denial notice to file appeal Process: Submit written appeal with supporting documentation Forms: Use Humana's appeal form or Medicare model forms Decision timeline: 7 days for standard appeals, 72 hours for expedited

Expedited Appeals

Request expedited review if waiting for standard timeline could:

  • Seriously jeopardize your life or health
  • Significantly reduce ability to regain maximum function

Contact: 866-737-5113 for expedited requests

External Review (California IMR)

If Humana upholds the denial, California residents can request Independent Medical Review through:

DMHC (for most plans): healthhelp.ca.gov or 888-466-2219 Timeline: 45 days for standard IMR, 72 hours for expedited Cost: Free to patients Success rates: California IMRs have high reversal rates for medically necessary treatments

Common Denial Reasons & Solutions

Denial Reason How to Overturn Documentation Needed
Missing genetic confirmation Submit complete genetic testing SMN1 deletion analysis, SMN2 copy number
Inadequate clinical documentation Provide comprehensive clinical notes Neurological exam, motor assessments, specialist evaluation
Duplicative therapy Document discontinuation of previous agent Treatment timeline, discontinuation date
Dosing/weight gaps Submit current measurements Recent weight, BSA calculations, dosing rationale
Lack of specialist involvement Obtain neuromuscular specialist consultation Specialist evaluation and treatment recommendation

Financial Assistance Options

Several programs can help reduce out-of-pocket costs:

Manufacturer Support

Genentech Patient Foundation: May provide assistance for eligible patients Copay assistance: Available for commercial insurance (not Medicare) Patient access programs: Evrysdi patient support

Foundation Grants

  • Patient Advocate Foundation: Copay relief programs
  • HealthWell Foundation: Disease-specific grants
  • National Organization for Rare Disorders (NORD): Patient assistance

State Programs

California may have additional assistance programs for rare disease medications. Check with your social worker or patient navigator.

When navigating complex insurance approvals for specialty medications like Evrysdi, many patients and providers benefit from expert guidance. Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical documentation to create targeted, evidence-backed rebuttal letters. Their platform helps identify the specific denial basis and crafts point-by-point responses aligned with each payer's own rules, potentially saving weeks of back-and-forth with insurance companies.

FAQ

How long does Humana prior authorization take for Evrysdi in California? Standard PA decisions are made within 72 hours. Expedited reviews for urgent cases are completed within 72 hours of request. Complex cases requiring additional clinical review may take longer.

What if Evrysdi is non-formulary on my Humana plan? You can request a formulary exception through the same prior authorization process. Provide clinical justification for why Evrysdi is medically necessary compared to formulary alternatives.

Can I get temporary supplies while waiting for approval? Humana may provide up to 31 days of transition supply in certain circumstances. Contact CenterWell Specialty Pharmacy to discuss emergency supply options.

Does step therapy apply if I've been on Spinraza outside California? Previous therapy history follows you regardless of location. Document your Spinraza experience, including efficacy, tolerability, and reasons for switching to Evrysdi.

What happens if I miss the 65-day appeal deadline? Missing Medicare appeal deadlines typically forfeits your right to appeal that specific denial. However, you may be able to request a new prior authorization with additional documentation.

Can my doctor request a peer-to-peer review? Yes, prescribers can request to speak directly with Humana's medical director. This is often effective for complex cases where written documentation may not fully convey clinical nuances.

Are there age restrictions for Evrysdi coverage? Evrysdi is FDA-approved for all ages, including infants. However, some payers may have age-specific coverage criteria. Check your plan's medical policy for any age-related restrictions.

How do I verify my specialist is in-network? Use Humana's provider directory to confirm your neuromuscular specialist is in-network. Out-of-network specialists may affect coverage decisions and increase costs.

Sources & Further Reading

Disclaimer: This information is educational and not medical advice. Coverage policies and procedures may change. Always verify current requirements with Humana directly and consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals and prior authorizations, consider consulting with organizations like Counterforce Health that specialize in navigating complex coverage determinations.

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