Evrysdi (risdiplam oral solution and tablets – Genentech/Roche) — Cigna

Initial criteria

• Baseline motor ability assessment that suggests spinal muscular atrophy (based on age, motor ability, and development) has been performed from ONE of the following exams (Bayley Scales of Infant and Toddler Development OR Children’s Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP-INTEND) OR Hammersmith Functional Motor Scale Expanded (HFMSE) OR Hammersmith Infant Neurological Exam Part 2 (HINE-2) OR Motor Function Measure-32 Items (MFM-32) OR Revised Upper Limb Module (RULM) test OR World Health Organization motor milestone scale) [documentation required]
• Patient has had a genetic test confirming the diagnosis of spinal muscular atrophy with bi-allelic pathogenic variants in the survival motor neuron 1 (SMN1) gene [documentation required]
• Patient meets ONE of the following: (a) Patient has two or three survival motor neuron 2 (SMN2) gene copies [documentation required] OR (b) Patient meets BOTH of the following: (1) Patient has four survival motor neuron 2 (SMN2) gene copies [documentation required]; AND (2) Patient has objective signs consistent with spinal muscular atrophy Types 1, 2, or 3 [documentation required]

Approval duration

4 months