By Counterforce Health Team in Evrysdi (risdiplam) —

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

Answer Box: Fast Track to Approval

Evrysdi (risdiplam) requires prior authorization from Humana in New Jersey. The fastest path: Have your neurologist submit genetic testing results (SMN1 deletion confirmation), baseline motor function scores (CHOP-INTEND or HFMSE), and a medical necessity letter through Humana's provider portal. Most decisions arrive within 1-2 business days for electronic submissions. If denied, you have 65 days to appeal and can request New Jersey's Independent Health Care Appeals Program (IHCAP) for external review after completing Humana's internal appeals process.

Start today: Contact your prescribing neurologist to gather genetic test results and motor assessments, then submit through Humana's prior authorization portal.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Documentation
  5. Step-by-Step: Fastest Path to Approval
  6. Specialty Pharmacy Network
  7. Common Denial Reasons & Solutions
  8. Appeals Process in New Jersey
  9. Cost Assistance Programs
  10. FAQ

Who Should Use This Guide

This guide helps New Jersey residents with Humana Medicare Advantage or commercial plans who need Evrysdi (risdiplam) for spinal muscular atrophy (SMA). You'll find step-by-step instructions whether you're:

  • Starting a new Evrysdi prescription
  • Appealing a recent denial
  • Switching from another SMA therapy
  • Moving to New Jersey from another state

Expected outcome: With proper documentation, Humana approves most medically necessary Evrysdi requests. Their Medicare Advantage denial rate is approximately 3.5%—among the lowest of major insurers—though specialty drugs require thorough clinical justification.

Member & Plan Basics

Coverage Requirements

Requirement Details Verification
Active Humana Coverage Medicare Advantage, Part D, or commercial plan in good standing Check member ID card; call member services
Prior Authorization Mandatory for all Evrysdi prescriptions due to high cost (~$340,000/year) Humana PA requirements
Specialty Pharmacy Must use Humana-preferred network (CenterWell, Accredo) Verify network status to avoid automatic denials
Prescriber Requirements Neurologist with SMA expertise preferred Include specialist credentials in PA submission
Note: Humana is reducing prior authorization requirements by one-third starting January 2026, but specialty medications like Evrysdi will continue requiring PA due to cost and complexity.

Clinical Criteria Requirements

Primary Indication

Evrysdi must be prescribed for FDA-approved SMA treatment in patients 2 months and older. Key clinical requirements include:

Genetic Confirmation (Required)

  • Homozygous SMN1 exon 7 deletion, OR
  • Compound heterozygous SMN1 mutations
  • Submit original lab reports with genetic testing results

Motor Function Documentation

  • Baseline assessments using validated scales:
    • CHOP-INTEND (infants/severe cases)
    • HFMSE (ambulatory patients)
    • RULM (upper limb function)
  • Document current symptoms and expected progression without treatment

Exclusion Criteria

  • No concurrent use with Spinraza (nusinersen) or Zolgensma
  • No invasive mechanical ventilation (non-invasive for sleep/naps acceptable)
  • Avoid in severe hepatic impairment

Coding & Documentation

Essential Codes

Code Type Details Usage
ICD-10 G12.0 (infantile SMA), G12.1 (other inherited SMA), G12.8 (other SMA) Include on all prescriptions and PA forms
HCPCS J8499 (oral prescription drug, non-chemotherapeutic) For billing and PA submissions
NDC 50242-011-XX (60mg powder for solution) Verify current NDC with pharmacy

Weight-Based Dosing Documentation

  • 2 weeks to <2 years: 0.15 mg/kg once daily
  • ≥2 years, <20 kg: 0.25 mg/kg once daily
  • ≥2 years, ≥20 kg: 5 mg once daily (maximum dose)

Include current weight and calculated daily dose in all submissions.

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient/Caregiver)

  • Insurance card and member ID
  • Complete genetic testing reports
  • Recent neurology visit notes
  • Previous SMA therapy records (if applicable)

2. Prescriber Completes PA Submission (Neurologist)

  • Submit through Humana provider portal
  • Include medical necessity letter addressing:
    • SMA type and genetic confirmation
    • Motor function decline or risk
    • Why Evrysdi is appropriate choice
    • Expected treatment outcomes

3. Enroll in Bridge Program (Same Day)

Contact Genentech MySMA Support at 833-387-9734 for up to 60 days of free medication during PA review.

4. Track PA Status (Within 48 Hours)

  • Electronic submissions: 85-95% decided within 1 business day
  • Paper submissions: Up to 15 days
  • Check status via Humana provider or member portal

5. Arrange Specialty Pharmacy (Upon Approval)

Humana will direct prescription to preferred network pharmacy (typically CenterWell or Accredo) for monthly shipments.

Specialty Pharmacy Network

Humana-Preferred Options

Pharmacy Contact Services
CenterWell Specialty Via Humana provider portal Clinical support, adherence monitoring, financial assistance coordination
Accredo 855-525-7995 SMA-specific care team, home delivery, injection training if needed

Important: Using out-of-network specialty pharmacies may result in automatic PA denials. Verify network status before filling prescriptions.

Shipment Process

  1. Specialty pharmacy contacts patient within 24-48 hours of approval
  2. Verify insurance coverage and shipping address
  3. Schedule monthly deliveries (typically 30-day supply)
  4. Provide clinical support and adherence monitoring

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Missing genetic confirmation Submit complete SMN1 testing results Original lab reports showing chromosome 5q deletions/mutations
Insufficient motor documentation Provide baseline functional assessments CHOP-INTEND, HFMSE, or RULM scores with dates
Concurrent therapy concerns Clarify treatment timeline Records showing discontinuation of Spinraza/Zolgensma
Age/weight documentation gaps Submit current measurements Recent clinic visit notes with weight-based dosing calculations
Non-preferred pharmacy Transfer to network provider Contact CenterWell or Accredo for prescription transfer
From our advocates: "We've seen families successfully overturn denials by submitting a comprehensive motor function timeline showing decline over 3-6 months. Include specific milestone losses and CHOP-INTEND score changes—this concrete evidence often convinces reviewers that intervention is urgent."

Appeals Process in New Jersey

Humana Internal Appeals (First Step)

  • Deadline: 65 days from denial notice
  • Timeline: 72 hours for expedited, 7-30 days standard
  • Submission: Humana member portal or mail to:Humana Grievances and Appeals
    P.O. Box 14546
    Lexington, KY 40512-4546

Required Appeal Documentation

  • Copy of original denial letter
  • Updated medical necessity letter from neurologist
  • Additional clinical evidence (recent assessments, peer-reviewed studies)
  • Patient/family impact statement

New Jersey External Review (IHCAP)

If Humana denies your internal appeal, New Jersey residents can request independent external review:

  • Deadline: 4 months from Humana's final denial
  • Process: Submit to NJ Department of Banking and Insurance
  • Timeline: 60 days standard, 72 hours expedited
  • Cost: Free to patients
  • Success Rate: External reviews favor consumers in approximately 50% of cases nationwide

Contact IHCAP: 1-888-393-1062 or file online at dobinsure.nj.gov

Cost Assistance Programs

Manufacturer Support

  • Evrysdi Co-pay Program: Reduces out-of-pocket costs for eligible commercial insurance patients
  • Genentech Patient Foundation: Free medication for qualifying uninsured/underinsured patients
  • MySMA Support: Comprehensive case management and financial assistance navigation

Contact: 833-387-9734 or EvrysdiCopay.com

New Jersey State Resources

  • NJ FamilyCare: Medicaid expansion covering SMA treatments
  • Pharmaceutical Assistance to the Aged and Disabled (PAAD): Prescription assistance for seniors and disabled residents

Clinician Corner: Medical Necessity Letter Essentials

Required Components

  1. Patient demographics and insurance information
  2. Genetic testing confirmation with specific mutations identified
  3. SMA type classification and symptom onset timeline
  4. Current motor function status with validated assessment scores
  5. Treatment rationale explaining why Evrysdi is appropriate
  6. Expected outcomes and monitoring plan
  7. Prescriber credentials and SMA expertise

Supporting Evidence to Include

  • FDA labeling information for approved indications
  • Recent clinical trial data (FIREFISH, SUNFISH studies)
  • Professional society guidelines (Child Neurology Society, SMA Foundation)
  • Patient-specific factors favoring oral therapy over alternatives

FAQ

How long does Humana prior authorization take in New Jersey? Electronic submissions typically receive decisions within 1-2 business days. Paper submissions can take up to 15 days. Request expedited review if treatment delay could cause health deterioration.

What if Evrysdi isn't on Humana's formulary? Submit a formulary exception request with medical necessity documentation. Humana covers non-formulary medications when medically necessary and no suitable alternatives exist.

Can I appeal if I live in New Jersey but have coverage from another state? Yes, New Jersey residents can use IHCAP for external review regardless of where their insurance plan is based, as long as it's a state-regulated plan (not self-funded employer plans).

Does step therapy apply to Evrysdi? Humana doesn't typically require step therapy for Evrysdi, but you may need to document why it's preferred over Spinraza or explain previous therapy failures.

What happens if my appeal is denied? After exhausting Humana's internal appeals, file with IHCAP for external review. If still denied, consult with patient advocacy organizations or legal assistance programs.

How do I expedite an appeal for urgent cases? Call Humana at 800-867-6601 and request expedited review. Provide documentation showing how treatment delays could cause serious health deterioration.

When to Get Professional Help

Consider working with specialized appeal services like Counterforce Health if you're facing complex denials or have already been denied once. These services analyze denial letters, identify specific policy gaps, and draft evidence-backed appeals tailored to Humana's requirements. They can be particularly valuable for families navigating multiple denials or dealing with unusual clinical circumstances.

Professional appeal assistance becomes especially important when dealing with high-cost medications like Evrysdi, where insurers scrutinize every detail of the medical necessity justification.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with Humana and consult your healthcare provider for medical decisions. For personalized assistance with New Jersey insurance issues, contact the NJ Department of Banking and Insurance Consumer Hotline at 1-800-446-7467.

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