By Counterforce Health Team in Evrysdi (risdiplam) —

How to Get Evrysdi (Risdiplam) Covered by UnitedHealthcare in Georgia: Prior Authorization, Appeals, and Financial Assistance Guide

Answer Box: Getting Evrysdi Covered by UnitedHealthcare in Georgia

UnitedHealthcare requires prior authorization for Evrysdi (risdiplam) with specific clinical criteria including genetic confirmation of SMA, ventilation status documentation, and proof that other SMN-modifying therapies aren't being used concurrently. If denied, you have 180 days to file an internal appeal, then 60 days after final denial to request external review through the Georgia Department of Insurance. Start by having your doctor submit comprehensive documentation including genetic test results, motor function assessments, and prior therapy history through the UnitedHealthcare provider portal.

Table of Contents

  1. Understanding UnitedHealthcare's Evrysdi Coverage Requirements
  2. Step-by-Step: Fastest Path to Approval
  3. What Drives Your Out-of-Pocket Costs
  4. Investigating Your Benefits
  5. Financial Assistance Options
  6. Requesting Tier Exceptions
  7. Appeals Process in Georgia
  8. Common Denial Reasons & Solutions
  9. Pharmacy Coordination Tips
  10. Renewal and Annual Changes
  11. Conversation Scripts
  12. FAQ

Understanding UnitedHealthcare's Evrysdi Coverage Requirements

UnitedHealthcare classifies Evrysdi as a specialty medication requiring prior authorization through OptumRx. The drug typically sits in the highest formulary tier (Tier 3 or 4), meaning maximum cost-sharing until you reach the annual out-of-pocket limit.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Evrysdi prescriptions Provider portal or PA forms UHC PA Policy
Genetic Confirmation SMN1 gene mutation/deletion documentation Medical records, genetic testing reports UHC PA Requirements
Ventilation Status Not dependent on invasive ventilation Clinical assessment notes UHC PA Policy
Therapy Restrictions No concurrent Spinraza or active Zolgensma Treatment history documentation UHC PA Requirements
Specialty Pharmacy Must use Optum Specialty Pharmacy network Pharmacy directory UHC Provider Resources

Step-by-Step: Fastest Path to Approval

  1. Gather Required Documentation (Patient/Clinic)
    • Genetic test results showing SMN1 mutation/deletion
    • Motor function assessments (CHOP INTEND, HINE-2, HFMSE, RULM, or MFM-32)
    • Prior therapy history and outcomes
    • Current ventilation status documentation
  2. Submit Prior Authorization (Prescriber)
    • Complete UHC PA forms with comprehensive clinical justification
    • Submit through provider portal or fax
    • Timeline: UHC responds within 15 calendar days (72 hours for urgent cases)
  3. Coordinate Specialty Pharmacy (Patient/Clinic)
    • Contact Optum Specialty Pharmacy once PA approved
    • Provide insurance information and shipping preferences
    • Timeline: 2-3 business days for first shipment
  4. Apply for Financial Assistance (Patient)
    • Submit Genentech copay program application if commercially insured
    • Apply to PAN Foundation SMA fund if income-eligible
    • Timeline: 1-2 weeks for approval
  5. Monitor Authorization Status (Patient/Clinic)
    • Check UHC provider/member portals regularly
    • Follow up if no response within stated timeframes
    • Request peer-to-peer review if initial denial

What Drives Your Out-of-Pocket Costs

Evrysdi's cost to patients depends on several benefit design factors that UnitedHealthcare controls through their formulary structure.

Formulary Tier Placement

Evrysdi typically lands in the highest specialty tier, resulting in:

  • Coinsurance: 25-50% of drug cost until deductible and out-of-pocket maximum are met
  • Prior Authorization: Required regardless of tier
  • Specialty Pharmacy: Must use network specialty pharmacy
Note: Starting in 2025, Medicare Part D plans cap specialty drug out-of-pocket costs at $2,000 annually, but commercial plans may have higher limits.

Key Cost Variables

  • Annual deductible amount
  • Specialty tier coinsurance percentage
  • Out-of-pocket maximum
  • Whether you've met your deductible for the year

Investigating Your Benefits

Before starting treatment, gather specific information about your UnitedHealthcare plan's coverage.

Information to Record

Call UnitedHealthcare member services and document:

  • Formulary status: Is Evrysdi covered? What tier?
  • Prior authorization: Required? What documentation needed?
  • Specialty pharmacy: Which network pharmacies can dispense?
  • Cost-sharing: Deductible, coinsurance, out-of-pocket maximum
  • Step therapy: Are there preferred alternatives you must try first?

Questions to Ask Your Insurer

  1. "What tier is Evrysdi on my specific plan?"
  2. "What's my specialty drug coinsurance percentage?"
  3. "How much have I spent toward my out-of-pocket maximum this year?"
  4. "Are there any quantity limits or dosing restrictions?"
  5. "What happens if my preferred specialty pharmacy is out-of-network?"

Financial Assistance Options

Multiple programs can help reduce Evrysdi's cost, but eligibility varies significantly.

Manufacturer Copay Program

Genentech Evrysdi Co-pay Program offers substantial savings for eligible patients:

  • Eligibility: Commercial insurance only (no Medicare/Medicaid)
  • Benefit: Up to $25,000 annually in copay assistance
  • Application: Call (833) 387-9734 or visit EvrysdiCopay.com

Foundation Grants

PAN Foundation Spinal Muscular Atrophy Fund:

  • Grant Amount: Up to $6,500 annually
  • Eligibility: SMA diagnosis, health insurance coverage, income ≤400% Federal Poverty Level
  • Application: Online at PAN Foundation or call 1-866-316-7263

Georgia-Specific Programs

  • Georgia Medicaid: Coverage for income-eligible individuals with disabilities
  • Katie Beckett Waiver: For children with complex medical needs (parental income may be disregarded)
  • SSI/SSDI: Federal disability benefits that can help with medical costs

Requesting Tier Exceptions

If Evrysdi isn't covered or requires prohibitive cost-sharing, your doctor can request a formulary exception.

When to Request Exceptions

  • Evrysdi is non-formulary (not covered at all)
  • High-tier placement creates unaffordable cost-sharing
  • Step therapy requirements can't be met due to contraindications

Exception Documentation Needed

Your prescriber should include:

  • Medical necessity statement explaining why Evrysdi is required
  • Documentation of contraindications to preferred alternatives
  • Evidence that step therapy requirements would be harmful or ineffective
  • Clinical guidelines supporting Evrysdi use for your specific situation
Tip: Exception requests have the same timeline as prior authorizations (72 hours standard, 24 hours urgent).

Appeals Process in Georgia

Georgia provides structured appeal rights when UnitedHealthcare denies coverage.

Internal Appeals Timeline

  • Filing Deadline: 180 days from denial notice
  • UHC Response Time: 30 days (72 hours if expedited)
  • Required Documents: Denial letter, medical records, updated necessity letter

External Review Through Georgia DOI

  • Filing Deadline: 60 days after final internal denial
  • Cost: Free to consumers
  • Timeline: 30 business days (72 hours if expedited)
  • How to File: Submit request at Georgia DOI Consumer Portal

Escalation Strategy

  1. Start with internal appeal including all supporting documentation
  2. Request peer-to-peer review between your doctor and UHC medical director
  3. If denied, immediately file external review with Georgia DOI
  4. Consider involving Counterforce Health for expert appeal assistance

Common Denial Reasons & Solutions

Denial Reason How to Overturn
Missing genetic confirmation Submit genetic testing report showing SMN1 mutation/deletion
Inadequate motor function documentation Provide baseline assessments using standardized scales (CHOP INTEND, HFMSE, etc.)
Concurrent therapy concern Document discontinuation of other SMN-modifying treatments
Insufficient medical necessity Include detailed clinical rationale and treatment goals
Ventilation dependency Provide pulmonary function tests and ventilation assessment

Pharmacy Coordination Tips

Evrysdi requires specialty pharmacy handling due to its complex dosing and storage requirements.

Working with Optum Specialty Pharmacy

  • Contact: Call Optum Specialty after PA approval
  • Information Needed: Insurance details, shipping address, prescriber contact
  • Delivery: Temperature-controlled shipping typically within 2-3 business days
  • Refills: Automatic refill programs available with 30-day advance notice

Coordination Between Providers

Ensure your prescriber's office:

  • Confirms PA approval before pharmacy contact
  • Provides accurate dosing based on current weight
  • Coordinates refill timing with specialty pharmacy
  • Monitors for any formulary changes at renewal

Renewal and Annual Changes

UnitedHealthcare can modify Evrysdi coverage during annual plan renewals.

What Can Change

  • Formulary tier placement (up to 3 times per year)
  • Prior authorization requirements
  • Preferred specialty pharmacy network
  • Cost-sharing percentages

Renewal Preparation

  • October-November: Review next year's formulary documents
  • December: Confirm continued coverage and any requirement changes
  • January: Resubmit PA if required by new plan terms
  • Throughout Year: Monitor for mid-year formulary updates
Important: Counterforce Health helps patients navigate these annual changes by tracking payer policy updates and assisting with renewed prior authorizations.

Conversation Scripts

Calling UnitedHealthcare Member Services

"Hi, I need to verify coverage for Evrysdi, generic name risdiplam, for spinal muscular atrophy treatment. Can you tell me: What tier is this medication on my plan? Is prior authorization required? What's my specialty drug coinsurance? Which specialty pharmacies are in-network for this medication?"

Requesting Peer-to-Peer Review (Clinic Staff)

"We received a denial for Evrysdi for our patient with SMA. We'd like to request a peer-to-peer review between Dr. [Name] and your medical director to discuss the clinical necessity. This is for a [pediatric/adult] patient with confirmed genetic diagnosis who meets all your published criteria."

Following Up on Delayed PA (Patient)

"I'm calling about prior authorization request [reference number] for Evrysdi submitted on [date]. It's been [X] days and we haven't received a response. Can you provide a status update and expected decision timeline? If there are any missing documents, please let me know what's needed."

FAQ

Q: How long does UnitedHealthcare prior authorization take for Evrysdi in Georgia? A: Standard PA decisions are made within 15 calendar days. Urgent requests receive responses within 72 hours. If UHC doesn't respond within these timeframes, the request is automatically approved.

Q: What if Evrysdi isn't on my UnitedHealthcare formulary? A: Your doctor can request a formulary exception with medical necessity documentation. The exception follows the same timeline as prior authorization (72 hours standard, 24 hours urgent).

Q: Can I get an expedited appeal if my condition is worsening? A: Yes. Both internal appeals with UHC and external reviews through Georgia DOI can be expedited if delay would seriously jeopardize your health. Expedited reviews are completed within 72 hours.

Q: Does UnitedHealthcare require step therapy for Evrysdi? A: UHC may require documentation that alternative SMA treatments (like Spinraza) have been considered or tried, unless contraindicated. However, patients can't receive Evrysdi concurrently with other SMN-modifying therapies.

Q: What happens if I switch from commercial insurance to Medicare? A: You'll lose eligibility for manufacturer copay assistance but may qualify for foundation grants. Medicare Part D plans have a $2,000 annual out-of-pocket cap for specialty drugs starting in 2025.

Q: Can I use a local pharmacy instead of Optum Specialty? A: Evrysdi typically requires specialty pharmacy dispensing due to its complexity. Using an out-of-network pharmacy usually results in no coverage or significantly higher costs.

Counterforce Health specializes in turning insurance denials into successful appeals for specialty medications like Evrysdi. Our platform analyzes denial letters, identifies specific policy gaps, and drafts evidence-backed appeals that address each payer's unique requirements—helping patients, clinicians, and pharmacies get life-changing treatments approved faster.

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 insurer and consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals, consider consulting with organizations like Counterforce Health that specialize in coverage advocacy.

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