By Counterforce Health Team in Evrysdi (risdiplam) —

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

Quick Answer: Getting Evrysdi (Risdiplam) Covered by Humana in Michigan

Yes, Humana covers Evrysdi (risdiplam) with prior authorization. Submit PA through your neurologist with genetic SMA confirmation, baseline motor assessments, and treatment history. Humana decides within 72 hours for standard requests. If denied, you have 65 days to appeal internally, then 127 days for Michigan external review through DIFS. Start with your prescriber calling Humana's provider line at 1-800-833-6917.

First step today: Have your doctor submit the PA request via Humana's provider portal with your genetic testing results and current motor function scores.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Deadlines
  4. Medical Necessity Criteria
  5. Costs and Financial Support
  6. Denials and Appeals
  7. Specialty Pharmacy Requirements
  8. Troubleshooting Common Issues
  9. FAQ

Coverage Basics

Is Evrysdi Covered by Humana?

Evrysdi (risdiplam) is covered under Humana Medicare Part D and Medicare Advantage plans, but requires prior authorization due to its specialty status and high cost (approximately $340,000 annually). The medication is typically placed on a high-tier formulary requiring documentation of medical necessity.

Which Humana Plans Cover Evrysdi?

  • Medicare Part D: All Humana Part D plans include Evrysdi on formulary with PA
  • Medicare Advantage: Coverage varies by specific plan; check your formulary at Humana's drug list tool
  • Commercial plans: Coverage varies; verify through your specific plan documents
Note: Humana has a relatively low Medicare Advantage denial rate of 3.5% when proper documentation is submitted, making thorough preparation crucial.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Gather Required Documentation (Patient/Caregiver)
    • Insurance card and member ID
    • Complete genetic testing results confirming SMA
    • Recent motor function assessments (CHOP INTEND, HINE-2, or HFMSE scores)
    • Documentation of prior treatments and outcomes
  2. Schedule Neurologist Visit (Patient)
    • Obtain current weight for dosing calculations
    • Complete baseline motor assessments if not recent
    • Discuss treatment goals and monitoring plan
  3. Submit PA Request (Prescriber)
    • Use Humana provider portal or PA search tool
    • Include all required documentation (see criteria below)
    • Submit via electronic portal for fastest processing (85% approved within 1 business day)
  4. Track Status (Patient/Prescriber)
    • Monitor through provider portal
    • Contact Humana at 1-800-833-6917 for status updates
    • Typical response: 72 hours for standard requests
  5. If Approved (All)
    • Prescription automatically routed to CenterWell Specialty Pharmacy
    • Patient receives delivery scheduling call within 24-48 hours

Timing and Deadlines

Request Type Humana Decision Timeline Your Action Deadline
Standard PA 72 hours (95% within 1 business day by 2026) Submit complete documentation
Expedited PA 24 hours Must justify medical urgency
Internal Appeal 7 days (Part D), 30 days (Part C) File within 65 days of denial
External Review (Michigan) 60 days standard, 72 hours expedited File within 127 days via DIFS

Michigan-Specific Appeal Rights

Michigan's Patient's Right to Independent Review Act provides additional protections. After exhausting Humana's internal appeals, you can file with the Michigan Department of Insurance and Financial Services (DIFS) for an independent medical review.

Key Michigan deadlines:

  • 127 days to file external review after final internal denial (longer than federal 120-day standard)
  • 72 hours for expedited external review with physician letter stating urgency
  • Contact DIFS at 877-999-6442 for assistance

Medical Necessity Criteria

Required Documentation Checklist

Genetic Confirmation:

  • Documented biallelic SMN1 gene deletion or mutation
  • SMA type classification (Type 1, 2, 3, or 4)
  • Genetic testing report with laboratory certification

Clinical Assessment:

  • Baseline motor function scores:
    • CHOP INTEND (for infants/Type 1 SMA)
    • HINE-2 (for sitting infants)
    • HFMSE (for ambulatory patients)
  • Current weight for dosing calculations
  • Treatment goals and expected outcomes

Treatment History (if applicable):

  • Prior SMA treatments (Spinraza, Zolgensma)
  • Outcomes, duration, and reasons for discontinuation
  • Contraindications to other therapies

Clinician Corner: Medical Necessity Letter

Your neurologist's letter should include:

  1. Patient's SMA diagnosis with genetic confirmation and type
  2. Current functional status with objective motor scores
  3. Treatment rationale citing FDA labeling for all SMA types
  4. Prior therapy history and outcomes (if applicable)
  5. Monitoring plan with follow-up assessments every 6 months
  6. Weight-based dosing calculation and administration plan

Costs and Financial Support

Expected Out-of-Pocket Costs

Costs vary significantly by plan phase and tier placement:

  • Deductible phase: Up to $590 average (2024)
  • Initial coverage: 10-50% coinsurance depending on tier
  • Coverage gap: 25% coinsurance
  • Catastrophic: Capped at $2,100 out-of-pocket maximum (2026 plans)

Financial Assistance Options

Manufacturer Support:

  • MySMA Support Program: Coverage gap assistance and copay support
  • Temporary supply (up to 30 days) during PA processing for eligible patients

Additional Resources:

  • Patient Access Network (PAN) Foundation
  • HealthWell Foundation
  • State pharmaceutical assistance programs
From our advocates: "We've seen families successfully reduce their Evrysdi costs from over $1,000 monthly to under $50 by combining manufacturer copay assistance with foundation grants. Start applications early—some programs have waiting lists during high-demand periods."

Denials and Appeals

Common Denial Reasons and Solutions

Denial Reason How to Overturn
Insufficient genetic documentation Submit complete genetic testing report with biallelic SMN1 confirmation
Missing baseline motor assessments Provide CHOP INTEND, HINE-2, or HFMSE scores from neurologist
Lack of treatment history Document prior therapies, outcomes, and reasons for switching
Dosing concerns Include current weight and dosing calculation based on 0.2mg/kg/day
"Not medically necessary" Cite FDA approval for all SMA types and peer-reviewed efficacy data

Appeals Playbook for Humana in Michigan

Level 1: Internal Appeal

  • Deadline: 65 days from denial notice
  • Timeline: 7 days for Part D, 30 days for Part C
  • How to file: Humana appeals form or call 1-800-833-6917
  • Required: Denial letter, additional medical evidence, prescriber letter

Level 2: External Review

  • Deadline: 127 days after final internal denial
  • Timeline: 60 days standard, 72 hours expedited
  • How to file: DIFS External Review Request or call 877-999-6442
  • Required: All prior documentation, physician urgency letter (for expedited)

When to Request Expedited Review

Request expedited appeals when:

  • Patient shows motor function decline without treatment
  • Delay would cause irreversible progression
  • Current therapy has failed and immediate switch needed

Include physician letter stating: "Delay in Evrysdi treatment poses serious risk to patient's motor function and quality of life due to progressive nature of SMA."

Specialty Pharmacy Requirements

CenterWell Specialty Pharmacy

Humana requires Evrysdi dispensing through CenterWell Specialty Pharmacy. After PA approval:

  1. Prescription routing: Automatically transferred to CenterWell
  2. Patient contact: CenterWell calls within 24-48 hours for delivery scheduling
  3. Preparation: Liquid formulation constituted from powder (takes 1-2 business days)
  4. Delivery: 30-day supply shipped directly to patient with dosing syringes

Dosing and Administration

  • Liquid: For all ages/weights; constituted to 0.75mg/mL
  • Tablets: For patients ≥2 years and ≥20kg; 0.25mg tablets
  • Supplies included: Appropriate dosing syringes, ENFit adapters if needed

Troubleshooting Common Issues

PA Portal Problems

  • Portal down: Call Humana provider services at 1-800-833-6917
  • Missing forms: Access current PA forms at Humana provider portal
  • Upload errors: Fax to number provided in portal (verify current number)

Documentation Issues

  • Genetic testing delays: Request expedited processing from lab
  • Missing motor scores: Schedule urgent neurology visit for assessment
  • Prior therapy records: Contact previous providers for complete documentation

FAQ

How long does Humana prior authorization take for Evrysdi in Michigan? Standard PA requests receive decisions within 72 hours, with 85% of electronic submissions approved within 1 business day. Expedited requests are decided within 24 hours.

What if Evrysdi is non-formulary on my Humana plan? Request a formulary exception through the same PA process. Include medical necessity documentation and evidence that formulary alternatives are inappropriate.

Can I request an expedited appeal in Michigan? Yes. Both Humana and Michigan DIFS offer expedited appeals for urgent medical needs. Include a physician letter stating that delay would seriously harm the patient.

Does step therapy apply if I've tried other SMA treatments outside Michigan? Yes. Prior treatment history from any location counts toward step therapy requirements. Provide complete medical records from all previous providers.

What happens if my appeal is denied by Humana? File for external review with Michigan DIFS within 127 days. Independent medical experts will review your case, and their decision is binding on Humana.

How do I track my PA status? Use the Humana provider portal for real-time updates, or call 1-800-833-6917 with your member ID for status information.

At Counterforce Health, we help patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to draft targeted, evidence-backed rebuttals. Our platform identifies the specific denial basis and creates point-by-point responses aligned to each plan's own rules, pulling the right citations and clinical evidence to build compelling cases for coverage approval.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For additional help with insurance appeals in Michigan, contact DIFS at 877-999-6442.

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