Medicare AdvantagePrior AuthHigh impact
Evrysdi® (risdiplam) (Revised)
Humana·Neurology, Pediatrics, Pharmacy·Medicare Advantage
Effective date
Aug 26, 2026
We identified it
Aug 26, 2026
Summary
Humana Medicare Advantage has revised its prior authorization policy for Evrysdi® (risdiplam), a medication for spinal muscular atrophy (SMA). The policy, effective November 11, 2020 with a recent revision date of August 26, 2026, establishes strict criteria for initial authorization and renewal, including genetic testing confirmation, functional assessments, specialist involvement, and prohibition of combination therapy with other SMN2-directed therapies. Billing teams must ensure all prior authorization requirements are met before dispensing to avoid claim denials.
Action Required
By September 26, 2026: Billing and pharmacy teams must implement the revised Evrysdi prior authorization requirements in all pharmacy billing systems and prior auth submission workflows. Update templates to require: (1) SMN1 gene deletion or 5q SMA genetic confirmation documentation, (2) SMA type I, II, or III diagnosis, (3) symptom onset before age 18 OR ≤4 SMN2 copies if asymptomatic, (4) neurology specialist involvement confirmation, (5) verification of non-permanent ventilation status, (6) baseline functional assessment (HFMSE, HINE, ULM, CHOP INTEND, or MFM32), (7) genetic testing or lab/chart notes, and (8) confirmation no concurrent SMN2-directed therapies (nusinersen) are being used. For renewal requests, require documentation of motor milestone improvement/maintenance and continued non-permanent ventilation status. Train pharmacy staff and prior auth specialists on the eight initial criteria and two renewal criteria. Configure system to flag and deny prescriptions without complete documentation. Set up alerts for pharmacy and providers when required supporting documentation is missing. Communicate requirements to all ordering neurologists and SMA specialists in network.