Subject: Specialty Quantity Limit Evrysdi 4084-H P2024a

Drug

EVRYSDI  (risdiplam)

Policy:

Program Description

The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. The recommended dosing parameters for all FDA-approved indications fall within the standard limits. Coverage of an additional quantity may be reviewed on a case-by-case basis upon request.

Covered Quantities

Medication	Standard Limit
Evrysdi for oral solution 60 mg bottle	2 bottles (120 mg) per 24 days
Evrysdi 5 mg tablets	30 tablets per 30 days

FDA-recommended Dosing

Oral Solution

Less than 2 months of age: 0.15 mg/kg once daily

2 months to less than 2 years of age: 0.2 mg/kg once daily

2 years of age and older weighing less than 20 kg: 0.25 mg/kg once daily

2 years of age and older weighing 20 kg or more: 5 mg once daily

Tablets

2 years of age and older weighing 20 kg or more: 5 mg once daily

Place of Service:

Outpatient

The above policy is based on the following references:

1. Evrysdi [package insert]. South San Francisco, CA: Genentech, Inc; February 2025.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

April 19, 2025