By Counterforce Health Team in Evrysdi (risdiplam) —

How to Get Evrysdi (Risdiplam) Covered by Humana in Illinois: Prior Authorization Requirements and Appeals Guide

Answer Box: Getting Evrysdi Covered by Humana in Illinois

Humana requires prior authorization for Evrysdi (risdiplam) in Illinois. To get approved: (1) Your neurologist must submit genetic testing confirming SMN1 deletion, baseline motor function scores (CHOP-INTEND, HFMSE, or RULM), and medical necessity documentation through Humana's provider portal. (2) If denied, you have 65 days to appeal, with automatic external review by an Independent Review Entity within 7 days. (3) Start by confirming your plan's formulary status and gathering required documentation today.

Table of Contents

Coverage Overview: Humana's Evrysdi Policy

Humana Medicare Advantage plans in Illinois require prior authorization for Evrysdi (risdiplam), a high-cost specialty medication for spinal muscular atrophy (SMA). The drug typically falls under Humana's Clinical Pharmacy Review (HCPR) process, which applies strict medical necessity criteria before approval.

Plan Types and Coverage

  • Medicare Advantage Part D: Prior authorization required
  • Commercial plans: Varies by employer group; most require PA
  • Medicaid managed care: Subject to state Medicaid criteria plus Humana's additional requirements

Evrysdi's annual cost can reach approximately $340,000, making it one of the most scrutinized medications in Humana's formulary management system.

Medical Necessity Requirements

Core Approval Criteria

Humana's approval for Evrysdi requires documentation of all the following:

Genetic Confirmation

  • Laboratory report showing bi-allelic SMN1 gene deletion or pathogenic variants
  • Must be from a CLIA-certified laboratory
  • Genetic counseling documentation (recommended but not always required)

Clinical SMA Diagnosis

  • ICD-10 codes: G12.0 (infantile SMA type I), G12.1 (other inherited SMA), or G12.9 (SMA, unspecified)
  • Confirmation by neurologist or neuromuscular specialist
  • Clinical presentation consistent with SMA phenotype

Baseline Motor Function Assessment Insurance requires at least one standardized assessment appropriate for the patient's age and motor abilities:

  • CHOP-INTEND: For non-sitting infants and weak patients
  • HFMSE: For patients who can sit or have some ambulation
  • RULM: For non-ambulatory patients with upper limb function
  • HINE-2 or MFM-32: Alternative assessments depending on age

Age and Dosing Requirements

  • No upper age limit for SMA treatment
  • Weight-based dosing must be documented and justified
  • For infants under 2 months, baseline testing may be waived to avoid treatment delays

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Formulary Status

Who: Patient or caregiver
Action: Log into Humana's member portal or call member services
Timeline: Same day
Documents needed: Member ID, drug name (risdiplam)

2. Gather Required Documentation

Who: Healthcare team
Documents to collect:

  • Genetic test results (SMN1 deletion confirmation)
  • Motor function assessment scores
  • Complete medical history and physical exam
  • Prior SMA therapy history (if applicable)
  • Current weight and dosing calculations

3. Submit Prior Authorization Request

Who: Prescribing physician or clinic staff
Method: Humana provider portal or fax
Timeline: Humana processes 85% of requests within one business day
Required forms: Humana's drug prior authorization form plus supporting documentation

4. Monitor Application Status

Who: Patient and healthcare team
Method: Provider portal or member services phone line
Follow-up: If no response within 3 business days, call Humana directly

5. Prepare for Potential Peer-to-Peer Review

Who: Prescribing physician
When: If initial review is pending or requires clinical discussion
Preparation: Have clinical notes, guidelines, and patient history readily available

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Missing genetic confirmation Submit complete genetic test report CLIA-certified lab results showing SMN1 deletion
Inadequate motor assessment Provide standardized baseline scores CHOP-INTEND, HFMSE, or RULM assessment by qualified clinician
Duplicate therapy concern Clarify therapy history and timeline Documentation of previous SMA treatments and washout periods
Insufficient medical necessity Strengthen clinical narrative Detailed letter explaining diagnosis, prognosis, and treatment goals
Dosing documentation gaps Provide weight-based calculations Current weight, BSA calculations, and dosing rationale

Appeals Process in Illinois

Internal Appeal (First Level)

Timeline: Must file within 65 days of denial notice
Humana's response time:

  • Standard appeals: 30 days for medical coverage, 7 days for Part D drugs
  • Expedited appeals: 72 hours when delay could harm health

How to file:

  1. Call Humana member services or use the online portal
  2. Submit written appeal with supporting documentation
  3. Include denial letter, member information, and clinical justification

External Review (Automatic)

If Humana upholds the denial, your case automatically goes to Maximus Federal Services (Independent Review Entity) for Medicare Advantage plans.

Timeline: 7 days for standard drug appeals, 72 hours for expedited reviews
Cost: Free to members
Decision: Binding on Humana if overturned

Illinois-Specific Resources

Illinois residents have additional support options:

  • Illinois Department of Insurance: (877) 527-9431 for consumer assistance
  • Illinois Attorney General Health Care Helpline: (877) 305-5145
  • External review deadline: 30 days after final internal denial (shorter than many states)
Tip: Illinois has strong consumer protections. If you're struggling with the appeal process, the state's consumer assistance programs can provide guidance and advocacy support.

Clinician Documentation Requirements

Medical Necessity Letter Checklist

Your neurologist's letter should include:

Patient Information

  • Age, weight, SMA type and severity
  • Date of genetic diagnosis confirmation
  • Current functional status and prognosis

Clinical Justification

  • Baseline motor function scores with assessment date
  • Treatment goals and expected outcomes
  • Why Evrysdi is appropriate vs. alternatives (Spinraza, Zolgensma)

Supporting Evidence

  • Reference to FDA labeling for approved SMA indications
  • Cite relevant clinical guidelines (e.g., SMA Care Guidelines from Cure SMA)
  • Peer-reviewed studies supporting efficacy in similar patients

Treatment Plan

  • Proposed dosing and monitoring schedule
  • Plans for follow-up motor assessments
  • Coordination with specialty pharmacy

Key Clinical Guidelines to Reference

Costs and Financial Assistance

Manufacturer Support Programs

Genentech Access Solutions offers several assistance options:

  • Copay support: May reduce out-of-pocket costs for eligible commercial insurance patients
  • Patient assistance program: For uninsured or underinsured patients
  • Bridge program: Temporary supply while insurance approval is pending

Contact: Visit Genentech Access Solutions or call their patient support line.

Additional Resources

  • Patient advocacy organizations: Cure SMA and MDA provide guidance and sometimes financial assistance
  • State pharmaceutical assistance programs: Illinois may have additional programs for high-cost medications
  • Hospital charity care: If receiving care at a major medical center, inquire about financial assistance programs
From our advocates: We've seen cases where patients initially denied by Humana were approved after submitting more comprehensive motor function data and a detailed timeline of previous treatments. The key was working with a neurologist experienced in SMA to provide thorough documentation that directly addressed Humana's specific medical policy requirements.

FAQ: Evrysdi Coverage Questions

How long does Humana's prior authorization process take? Standard requests: Up to 30 days for medical coverage, 7 days for Part D drugs. Expedited requests: 72 hours when medically urgent. Humana processes 85% of electronic requests within one business day.

What if Evrysdi isn't on my Humana formulary? You can request a formulary exception based on medical necessity. Your doctor must demonstrate why Evrysdi is medically necessary and why formulary alternatives aren't appropriate.

Can I get an expedited appeal if my condition is urgent? Yes. If waiting for a standard appeal could seriously harm your health, request an expedited appeal. Both Humana and the external reviewer must respond within 72 hours.

Does step therapy apply to Evrysdi? Some Humana plans may require trying other SMA treatments first, but medical exceptions are available if other treatments are contraindicated or have failed.

What happens if I move to Illinois from another state? Your Humana coverage should continue, but you may need to update your provider network and confirm your plan's specific formulary. Illinois' appeal rights will apply to any new denials.

How do I find an SMA specialist in Illinois? Contact Cure SMA's resource center or check with major academic medical centers like Northwestern, University of Chicago, or Rush University Medical Center.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed responses. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals that align with each payer's specific requirements, incorporating the right clinical evidence and procedural details to maximize approval chances.

For complex cases like Evrysdi approvals, having expert support in navigating prior authorization requirements and appeals can make the difference between approval and lengthy delays in accessing life-changing treatments.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and change frequently. Always verify current requirements with your specific Humana plan and consult with your healthcare provider regarding treatment decisions. For personalized assistance with insurance appeals, consider consulting with a patient advocate or the resources listed above.

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