By Counterforce Health Team in Evrysdi (risdiplam) —

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

Quick Answer: Getting Evrysdi Approved by UnitedHealthcare in California

UnitedHealthcare requires prior authorization for Evrysdi (risdiplam) with strict criteria: confirmed SMN1 gene mutation, no invasive ventilation dependency, and no concurrent Spinraza use. Submit through the UnitedHealthcare Provider Portal with genetic testing, motor function assessments (CHOP INTEND/HFMSE), and specialist documentation. Standard approval takes 15 days; expedited reviews complete within 72 hours. If denied, California's Independent Medical Review (IMR) overturns 68% of specialty drug denials. First step today: Gather genetic test results and contact your neurologist for baseline motor assessments.

Table of Contents

What This Guide Covers

This comprehensive guide helps patients with spinal muscular atrophy (SMA) and their healthcare teams navigate UnitedHealthcare's prior authorization process for Evrysdi (risdiplam) in California. We'll walk through the exact requirements, forms, timelines, and appeal strategies specific to California's regulatory environment.

Evrysdi is an oral SMN2 splicing modifier approved for SMA treatment in patients 2 months and older. With annual costs potentially reaching $340,000, securing insurance approval requires careful preparation and understanding of UnitedHealthcare's specific criteria.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical documentation to create targeted, evidence-backed responses. Their platform helps patients and providers navigate complex prior authorization requirements like those outlined in this guide.

Before You Start: Verify Your Coverage

Check Your Plan Type

California UnitedHealthcare members fall under different regulatory authorities:

  • HMO plans: Regulated by California's Department of Managed Health Care (DMHC)
  • PPO plans: May be regulated by California Department of Insurance (CDI)
  • Medicare Advantage: Federal oversight with California protections
Tip: Call the member services number on your insurance card to confirm your plan type and regulatory authority. This determines your appeal rights.

Formulary Status

Evrysdi typically appears on UnitedHealthcare's highest specialty tier, requiring:

  • Prior authorization
  • Specialty pharmacy dispensing through Optum Specialty Pharmacy
  • Step therapy restrictions (no concurrent Spinraza)

Required Documentation Checklist

Essential Medical Records

Genetic Testing Confirmation

  • SMN1 gene deletion/mutation documentation
  • SMN2 copy number (minimum 2 copies typically required)
  • Genetic counselor or specialist interpretation

Baseline Motor Function Assessment

  • CHOP INTEND scores for infants/non-sitters
  • HFMSE scores for ambulatory patients
  • HINE scores for younger children
  • Upper Limb Module for non-ambulatory patients

Clinical Documentation

  • SMA diagnosis with appropriate ICD-10 codes:
    • G12.0: Infantile SMA, Type I
    • G12.1: Other inherited SMA (Types II, III)
  • Neurologist consultation notes
  • Ventilation status documentation
  • Treatment history (Spinraza, Zolgensma)

Required Forms

Submit prior authorization through the UnitedHealthcare Provider Portal using:

  • Standard PA request form
  • Medical necessity documentation
  • Specialty pharmacy routing information
Note: As of 2025, UnitedHealthcare requires electronic submission only—no paper forms accepted.

Step-by-Step: Submitting Your Prior Authorization

Step 1: Provider Portal Setup

Your neurologist or prescribing physician must access the UnitedHealthcare Provider Portal and navigate to the prior authorization section.

Step 2: Complete Medical Necessity Form

Include all required elements:

  • Patient demographics and UnitedHealthcare member ID
  • SMA diagnosis with ICD-10 code
  • Genetic testing results
  • Baseline motor function scores
  • Treatment history and contraindications

Step 3: Upload Supporting Documentation

Attach:

  • Complete genetic testing report
  • Neurologist consultation notes
  • Motor function assessments
  • Any previous treatment records

Step 4: Specialty Pharmacy Coordination

Indicate Optum Specialty Pharmacy for dispensing and include:

  • Patient weight for dosing calculations
  • Administration instructions
  • Monitoring requirements

Step 5: Submit and Track

  • Submit electronically through the portal
  • Record confirmation number
  • Set calendar reminder for follow-up

Understanding UnitedHealthcare's Decision Timeline

Request Type Response Time California Requirements
Standard PA 15 calendar days Must provide written determination
Expedited/Urgent 72 hours For cases where delay could harm patient
Reauthorization 15 calendar days Required annually

When to Request Expedited Review

Request urgent review if:

  • Patient is experiencing rapid motor decline
  • Delay could worsen SMA progression
  • Current treatment is failing or causing adverse effects

Include physician attestation explaining medical urgency and potential harm from delay.

Common Denial Reasons and Solutions

Denial Reason Required Fix Documentation Needed
Missing genetic confirmation Submit SMN1/SMN2 testing Complete genetic report with interpretation
Insufficient motor assessment Provide baseline scores CHOP INTEND, HFMSE, or HINE results
Concurrent therapy concern Clarify treatment history Documentation of Spinraza discontinuation
Age/weight documentation Submit current measurements Recent clinic visit notes with weight
Specialist requirement Neurologist involvement Consultation notes from SMA specialist

Medical Necessity Letter Checklist

Your neurologist's letter should include:

  • Specific SMA type and genetic confirmation
  • Baseline motor function with standardized scores
  • Prior treatments attempted and outcomes
  • Contraindications to alternative therapies
  • Treatment goals and monitoring plan
  • Literature supporting Evrysdi use

California Appeals Process: Your Rights

Internal Appeal (First Level)

  • Deadline: 180 days from denial
  • Timeline: UnitedHealthcare responds within 30 days (72 hours for urgent)
  • Submission: Electronic only via provider portal

Independent Medical Review (IMR)

California's external review process offers strong patient protections:

Success Rates:

  • Specialty drug appeals: 68% overturn rate
  • Rare disease treatments: 50-65% success rate

Process:

  1. File within 6 months of final internal denial
  2. No cost to patient
  3. Independent physician reviewers
  4. Decision within 45 days (7 days for urgent cases)

Contact Information:

From Our Advocates: "We've seen excellent IMR success when families include comprehensive motor function documentation and specialist letters explaining why Evrysdi is specifically needed over alternatives. The independent reviewers particularly value functional assessments showing disease progression."

Required IMR Documentation

  • Complete denial letters from UnitedHealthcare
  • All medical records and test results
  • Detailed physician letter of medical necessity
  • Published literature supporting treatment
  • Motor function assessments and trends

Costs and Financial Assistance

Insurance Coverage

With approval, UnitedHealthcare typically covers Evrysdi through their specialty pharmacy benefit, but patient responsibility varies by plan:

  • Specialty tier copays: $50-$500+ per month
  • Coinsurance: 10-50% of drug cost
  • Annual out-of-pocket maximums apply

Financial Assistance Options

Manufacturer Support:

Foundation Grants:

  • PAN Foundation SMA Fund: Covers insurance premiums and copays
  • Patient Access Network: Specialty drug assistance

State Programs:

  • Medi-Cal coverage for eligible families
  • California Children's Services for qualifying conditions

Renewal Requirements

Evrysdi authorization requires annual renewal with:

  • Updated motor function assessments
  • Clinical progress documentation
  • Continued specialist oversight
  • Weight-based dosing adjustments

Timeline: Submit renewal 30-60 days before expiration to avoid treatment gaps.

FAQ: Most Common Questions

Q: How long does UnitedHealthcare PA take in California? Standard requests: 15 calendar days. Expedited reviews for urgent cases: 72 hours. California law requires written determinations within these timeframes.

Q: What if Evrysdi isn't on my formulary? Request a formulary exception with medical necessity documentation. If denied, appeal through California's IMR process, which has high success rates for specialty drugs.

Q: Can I get expedited approval? Yes, if delay could harm your health. Your doctor must attest to medical urgency. UnitedHealthcare must respond within 72 hours for expedited requests.

Q: What happens if I'm denied after appeal? California residents can request Independent Medical Review (IMR) through DMHC. IMR decisions are binding on UnitedHealthcare and have a 68% success rate for specialty drugs.

Q: Do I need to use a specific pharmacy? Yes, UnitedHealthcare requires Optum Specialty Pharmacy for Evrysdi dispensing. They coordinate with your doctor for dosing and delivery.

Q: How much will I pay out-of-pocket? Costs vary by plan. Specialty tier copays range from $50-$500+ monthly. Manufacturer copay programs and foundation grants can significantly reduce costs.

Quick Reference Checklist

Before Starting:

  • Verify UnitedHealthcare plan type and formulary status
  • Confirm neurologist is in-network
  • Gather genetic testing results
  • Complete baseline motor function assessments

Required Documents:

  • SMN1 gene deletion/mutation confirmation
  • SMN2 copy number documentation
  • CHOP INTEND, HFMSE, or HINE scores
  • Neurologist consultation notes
  • Treatment history and contraindications

Submission Process:

  • Submit via UnitedHealthcare Provider Portal
  • Include all supporting documentation
  • Request expedited review if urgent
  • Record confirmation number and set follow-up reminder

If Denied:

  • File internal appeal within 180 days
  • Request peer-to-peer review if available
  • Prepare IMR application with DMHC
  • Contact DMHC Help Center: 888-466-2219

Understanding UnitedHealthcare's requirements and California's strong patient protections gives you the best chance of securing Evrysdi coverage. Counterforce Health provides additional support for complex appeals, helping families navigate denials with targeted, evidence-based responses that align with payer-specific requirements.

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider regarding treatment decisions. For official information about appeals and patient rights in California, contact the DMHC at 888-466-2219 or visit healthhelp.ca.gov.

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