Evrysdi® (risdiplam) (Revised)

By September 24, 2025: Billing team must implement the following prior authorization requirements for Evrysdi (risdiplam) claims: REQUIREMENTS: 1. Before submitting claims, verify the following with providers and obtain prior authorization: - Genetic testing results confirming SMN1 gene deletion or 5q SMA homozygous gene deletion/mutation - SMA type I, II, or III diagnosis documentation - Symptom onset prior to age 18 (or asymptomatic with ≤4 SMN2 copies) - Treating specialist is a neurologist experienced in SMA management - Patient does NOT require permanent ventilation (no tracheostomy, no >21 consecutive days non-invasive ventilation ≥16 hrs/day, no intubation) - Baseline functional assessment (HFMSE, HINE, ULM, CHOP INTEND, or MFM32) completed and submitted - Lab/genetic testing results and chart notes submitted - Confirmation that Evrysdi will NOT be combined with other SMN2-directed therapies (nusinersen) 2. For renewal requests, require documentation that: - Member shows improvement or maintenance in motor milestones vs. natural disease progression - Functional assessment evaluation submitted with renewal request - Member remains free of permanent ventilation 3. Update authorization request template in billing system to require all 8 initial criteria checkpoints 4. Add renewal criteria checklist for continuation-of-therapy requests 5. Train billing staff to flag claims missing genetic testing documentation or functional assessments for denial prevention Consequences: Claims submitted without prior authorization meeting all 8 criteria will be denied by Humana. Renewals without motor milestone documentation will be rejected.