By Counterforce Health Team in Evrysdi (risdiplam) —

Lowering Out-of-Pocket for Evrysdi (risdiplam) with Aetna (CVS Health) in Michigan: Copay, Tiering & Assistance

Answer Box: Fastest Path to Lower Evrysdi Costs in Michigan

Evrysdi (risdiplam) requires prior authorization with Aetna and typically sits on a high specialty tier. To minimize costs: (1) Apply for Genentech's copay program at EvrysdiCopay.com (up to $25,000 annually for commercial insurance), (2) Ask your neurologist to submit complete PA documentation including genetic testing and motor function scores, (3) If denied or high-tier, request a formulary exception citing medical necessity. Start with the copay assistance application today—it processes in 1-2 weeks and can reduce costs to $0.

Table of Contents

  1. What Drives Evrysdi Costs with Aetna
  2. Benefit Investigation: What to Ask
  3. Assistance Options: Copay Programs & Foundations
  4. Formulary Exceptions: Lowering Your Tier
  5. Pharmacy Choice: CVS Specialty Coordination
  6. Appeals on Cost Grounds
  7. Renewal Budgeting: Annual Changes
  8. Conversation Scripts
  9. FAQ

What Drives Evrysdi Costs with Aetna

Evrysdi's annual cost can reach $340,000 at list price, making your out-of-pocket expense heavily dependent on three key factors:

Formulary Tier Placement

Most Aetna plans place Evrysdi on a specialty tier with coinsurance rather than flat copays. For example:

  • Tier 4 (Specialty): 25-40% coinsurance after deductible
  • Tier 5 (Non-preferred specialty): 40-50% coinsurance after deductible

Prior Authorization Requirements

Aetna requires PA for all Evrysdi prescriptions under their specialty policy. The PA process can influence tier placement—approvals for medical necessity may qualify for lower cost-sharing.

Specialty Pharmacy Network

Aetna typically requires CVS Specialty Pharmacy for dispensing, which affects coordination with assistance programs and billing processes.

Note: Michigan patients have strong appeal rights through the Department of Insurance and Financial Services (DIFS) if cost-related denials occur.

Benefit Investigation: What to Ask

Before starting therapy, gather this cost information from Aetna:

Essential Questions for Member Services

Call the number on your ID card and ask:

  1. "What tier is Evrysdi (risdiplam) on my 2024 formulary?"
  2. "What's my specialty tier coinsurance percentage?"
  3. "Have I met my deductible, and what's my out-of-pocket maximum?"
  4. "Is CVS Specialty required, or can I use other in-network specialty pharmacies?"
  5. "Are there quantity limits or step therapy requirements?"

Information to Record

Document these details for assistance program applications:

Item Why It Matters Where to Find
Plan name & ID Required for all programs Insurance card
Deductible status Affects first-fill cost Member portal
Specialty coinsurance % Calculates your share Benefits summary
Out-of-pocket maximum Annual cost ceiling Plan documents

Assistance Options: Copay Programs & Foundations

Genentech Evrysdi Copay Program (Primary Option)

The Genentech Evrysdi Copay Program provides up to $25,000 annually for commercially insured patients, potentially reducing costs to $0.

Eligibility Requirements:

  • Valid prescription for FDA-approved SMA indication
  • Commercial insurance (excludes Medicare, Medicaid, TRICARE)
  • U.S. residency

How to Apply:

  1. Visit EvrysdiCopay.com or call (833) 387-9734
  2. Complete enrollment form with insurance details
  3. Program processes in 1-2 weeks
  4. Automatic re-enrollment if eligible

Independent Patient Assistance Foundations

PAN Foundation

NORD RareCare

  • Coverage: Medication copays, diagnostics for uninsured/underinsured patients
  • Apply: nordrarediseases.org with medical and financial documentation

MySMA Support Program

Genentech's MySMA Support provides:

  • Insurance navigation and coverage verification
  • Financial assistance program referrals
  • Product education and adherence support

Enrollment: Submit Patient Consent and Prescriber Foundation Forms via fax or online portal.

From our advocates: We've seen Michigan families reduce their Evrysdi costs from $8,000+ annually to under $100 by combining the Genentech copay program with PAN Foundation assistance. The key is applying to multiple programs simultaneously, as they can often be used together within program guidelines.

Formulary Exceptions: Lowering Your Tier

If Evrysdi is non-formulary or on a high-cost tier, request a formulary exception to secure lower cost-sharing.

When to Request an Exception

  • Evrysdi is non-formulary (not covered)
  • Placed on highest specialty tier with prohibitive coinsurance
  • Step therapy requirements don't align with your clinical history
  • Alternative SMA treatments contraindicated or failed

Required Documentation

Your neurologist should submit:

  1. Medical necessity letter explaining:
    • Confirmed SMA diagnosis with genetic testing
    • Prior treatment failures or contraindications to alternatives (Spinraza, Zolgensma)
    • Clinical rationale for Evrysdi specifically
    • Risk of disease progression without treatment
  2. Supporting clinical evidence:
    • Baseline motor function assessments (CHOP INTEND, HFMSE)
    • Genetic test results showing SMN gene mutation/deletion
    • Documentation of SMA type and severity
  3. Literature support:

Submission Process

Submit exceptions through:

  • Availity provider portal (electronic)
  • Aetna pharmacy PA phone/fax (verify current contact with member services)
  • Request expedited review if clinically urgent

Pharmacy Choice: CVS Specialty Coordination

CVS Specialty Requirements

Aetna typically requires CVS Specialty for Evrysdi dispensing. This affects cost management:

Advantages:

  • Streamlined PA processing through "Specialty Expedite" program
  • Integrated billing with assistance programs
  • Clinical support and adherence monitoring

Coordination Tips:

  1. Enroll in assistance programs before first fill to ensure proper billing setup
  2. Provide CVS Specialty with copay card information during enrollment call
  3. Confirm assistance program activation before each shipment

Alternative In-Network Options

If CVS Specialty cannot meet your needs:

  • Request network exception for another in-network specialty pharmacy
  • Provide clinical justification (geographic access, clinical monitoring needs)
  • Submit via member services with prescriber support letter

Appeals on Cost Grounds

When Cost-Based Appeals Are Relevant

  • Formulary exception denied
  • PA approved but placed on prohibitively expensive tier
  • Assistance programs insufficient to cover remaining costs
  • Medical necessity questioned affecting coverage level

Michigan-Specific Appeal Process

Internal Appeals with Aetna

  • Timeline: 60 days from denial letter for specialty medications
  • Decision timeframe: Up to 30 days (standard), 72 hours (expedited)
  • Required documentation:
    • Original denial letter
    • Clinical justification for coverage/tier exception
    • Financial hardship documentation if relevant

External Review through Michigan DIFS

If internal appeal fails:

  • Timeline: 127 days from Aetna's final denial
  • Process: File with Michigan DIFS via online form or phone (877-999-6442)
  • Decision: Up to 60 days (standard), 72 hours (expedited)
  • Binding: DIFS decisions are legally binding on Aetna
Tip: Michigan's external review process has strong patient protections. DIFS assigns independent medical experts with appropriate specialty knowledge to review your case.

Renewal Budgeting: Annual Changes

Plan Year Considerations

  • Formulary changes: Tier placement may shift annually
  • Benefit resets: Deductibles and out-of-pocket maximums restart January 1
  • Assistance program renewals: Most programs require annual re-enrollment

Planning Ahead

  1. Review formulary updates each open enrollment
  2. Re-enroll in assistance programs by December for continuous coverage
  3. Budget for first-quarter costs when deductibles reset
  4. Consider plan switching if Evrysdi coverage becomes unaffordable

Counterforce Health helps patients navigate these annual transitions by tracking formulary changes and optimizing assistance program combinations for maximum savings.

Conversation Scripts

Patient Script for Aetna Member Services

"Hi, I'm calling about coverage for Evrysdi, spelled E-V-R-Y-S-D-I, for spinal muscular atrophy. I need to understand:

  1. What tier is this medication on my formulary?
  2. What's my specialty tier coinsurance percentage?
  3. Is prior authorization required, and what's the process?
  4. Can you confirm CVS Specialty is required for dispensing?
  5. Are there any step therapy or quantity limit requirements?"

Clinic Staff Script for PA Submission

"This is [Name] from [Clinic] calling about a prior authorization for Evrysdi for our SMA patient [Patient Name], member ID [ID]. We have:

  • Genetic confirmation of SMA with SMN gene deletion
  • Baseline motor function assessments
  • Documentation that patient is not on concurrent Spinraza or Zolgensma
  • Weight-based dosing calculation per FDA label Can you confirm what additional documentation is needed and provide the fastest submission method?"

Financial Assistance Follow-up

"I'm calling to check the status of my Evrysdi copay assistance application submitted [date]. My reference number is [number]. Can you confirm:

  1. Current application status
  2. Expected activation date
  3. How this will coordinate with my CVS Specialty prescription
  4. Any additional steps needed from my side?"

FAQ

How long does Aetna PA take for Evrysdi in Michigan? Standard PA decisions take up to 30 days, but expedited reviews are available within 72 hours if delay could jeopardize health. Submit complete documentation to avoid delays.

What if Evrysdi is non-formulary on my Aetna plan? Request a formulary exception with medical necessity documentation. If denied, appeal through Aetna's internal process, then Michigan DIFS external review if needed.

Can I use manufacturer assistance with Aetna coverage? Yes, the Genentech copay program covers up to $25,000 annually for commercially insured patients. Government insurance (Medicare/Medicaid) is excluded.

Does step therapy apply if I've failed other SMA treatments outside Michigan? Yes, document prior treatment failures or contraindications to Spinraza or Zolgensma regardless of where treatment occurred. Include detailed clinical notes and dates.

How do I request expedited appeal for urgent Evrysdi coverage? Contact Aetna member services and explicitly request "expedited appeal." Provide physician documentation explaining health risks from treatment delay.

What assistance is available if I'm on Michigan Medicaid? Medicaid patients cannot use manufacturer copay programs but may qualify for independent foundations like PAN Foundation or NORD RareCare based on income.

Can I switch from CVS Specialty to another pharmacy? Request a network exception if another in-network specialty pharmacy better meets your needs. Provide clinical justification and prescriber support.

What happens to my costs when my plan year renews? Deductibles reset, formulary tiers may change, and assistance programs require re-enrollment. Plan ahead by reviewing changes during open enrollment.

This guide provides general information about insurance coverage and is not medical advice. Consult your healthcare provider for medical decisions and contact Michigan DIFS (877-999-6442) for insurance-related assistance.

Sources & Further Reading

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.