Provider Alert! Evrsydi available on Medicaid formulary with prior authorization requirements on Feb 1

Date: January 25, 2021
Attention: Neurologists and SMA specialists

Effective Date: February 1, 2021

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Prescribers should be aware that Evrysdi will be available to members through Texas Medicaid pharmacy benefit effective February 1. Access will require meeting clinical prior authorization criteria for Evrysdi (risdiplam).  Evrysdi is indicated for treatment of children (> 2 months of age) and adults (< 65 years of age) with Spinal Muscular Atrophy (SMA).

Evrysdi must be prescribed by, or in consultation with, a neurologist or a specialist in SMA.

How this impacts providers: A manual prior authorization of therapy will be approved for members who meet the following criteria:
Initial Prior Authorization Request (for 12-month period): 

• Client has a diagnosis of SMA type 1, 2 or 3 in the last 730 days (Supporting documentation must be provided along with baseline motor function tests) 
  • Medical record supports SM1 gene mutation or deletion 
  • Testing tools that can be used to demonstrate physical function include, but are not limited to: 
    • The Hammersmith Infant Neurological Exam (HINE) 
    • The Hammersmith Functional Motor Scale Expanded (HFSME) 
    • The Upper Limb Module (UML) or revised Upper Limb Module (RULM) 
    • Baseline 6MWT 
    • Children’s Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOPINTEND) 
• Client is between 2 months and 65 years of age 
• Client is NOT currently pregnant 
• Client does NOT have a diagnosis of hepatic disease or hepatic impairment 
• Requested dose is ≤ 5 mg/day 

Renewal Request (for 12-month period): 

• Client is between 2 months and 65 years of age 
• Client is NOT currently pregnant 
• Client had a positive response to treatment, demonstrated by improvement or no decline in function   

(Supporting documentation must be provided comparing baseline functional scores to current scores) 

Missed Dose Instruction 

• If patient is unable to swallow or vomiting occurs, another dose should NOT be administered to make up for the lost dose. 
• The patient should wait until the next day to take the next dose at the regularly scheduled time. 

Accidental Product Damage 

• Prescribers should direct patients to contact their pharmacy immediately in the event that a product has been damaged (spillage or inappropriate storage).  The pharmacy will contact the manufacturer (Genentech) for replacement product. 
• The Genentech Spoilage Program provides replacement for product that is not administered due to unforeseen patient clinical circumstances, subject to certain limitations and conditions.  Each request will be approved on a case-by-case basis.

Next steps for providers: Prescribers should adjust their prescribing patterns accordingly and communicate these changes to their staff. The revised Hepatitis C virus clinical prior authorization form is forthcoming. Providers can obtain the new form from the Navitus website once it is available.  

Resource: Navitus TX Medicaid Prior Authorization forms 

If you have any questions, please email the TCHP Pharmacy team at: TCHPPharmacy@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.