Forms and Documents

Quickly Enroll in MySMA Support™ brochure

The Quickly Enroll in MySMA Support brochure provides a step-by-step overview of using E-Submit (also known as Quick Enroll) to enroll patients in MySMA Support.

 

MySMA Support for Evrysdi Enrollment Forms

The Evrysdi Start Form includes the Patient Consent Form (page 4), which is to be completed by the patient, and the Prescriber Service Form (page 5), which is to be completed by the health care provider. Both pages must be completed for enrollment.

To download multiple files at once, select the checkbox next to each file you would like to download from the list above then click Download Selected. Documents will be downloaded as a .zip file.

Other Important Documents

Patient Road Map for MySMA Support by Genentech

This guide provides an overview of how MySMA Support may help patients who have been prescribed Evrysdi access their medicine.

Sample Letter of Medical Necessity – Patient New to Evrysdi

Use this sample letter as a guide when you draft a letter of medical necessity and submit a request for prior authorization to the patient's health insurance plan. This version is specifically written for patients starting treatment with Evrysdi.


Use the links below to find additional information to enclose in your letter.

FDA approval letter (Follow this link and search by the drug name)

Prescribing Information

Sample coding for Evrysdi

 

Sample Letter of Medical Necessity – Patient Converting to Evrysdi

Use this sample letter as a guide when you draft a letter of medical necessity and submit a request for prior authorization to the patient's health insurance plan. This version is specifically written for patients switching to Evrysdi from a different therapy.


Use the links below to find additional information to enclose in your letter.

FDA approval letter (Follow this link and search by the drug name)

Prescribing Information

Sample coding for Evrysdi

Sample Letter of Medical Necessity – Patient to Remain on Evrysdi

Use this sample letter as a guide when you draft a letter of medical necessity and submit a request for prior authorization or reauthorization to the patient's health insurance plan. This version is specifically written for patients remaining on Evrysdi.


Use the links below to find additional information to enclose in your letter.

FDA approval letter (Follow this link and search by the drug name)

Prescribing Information

Sample coding for Evrysdi

Sample Appeal Letter – Patient New to Evrysdi

Use this sample letter as a guide as you draft an appeal letter in the event the patient's health insurance plan denies coverage for Evrysdi. This version is specifically written for patients new to Evrysdi.

 

Use the links below to find additional information to enclose in your letter.

FDA approval letter (Follow this link and search by the drug name)

Prescribing Information

Sample coding for Evrysdi

Sample Appeal Letter – Patient Converting to Evrysdi

Use this sample letter as a guide as you draft an appeal letter in the event the patient's health insurance plan denies coverage for Evrysdi. This version is specifically written for patients switching to Evrysdi from a different therapy.


Use the links below to find additional information to enclose in your letter.

FDA approval letter (Follow this link and search by the drug name)

Prescribing Information

Sample coding for Evrysdi

Sample Appeal Letter – Patient to Remain on Evrysdi

Use this sample letter as a guide as you draft an appeal letter in the event the patient's health insurance plan denies coverage for Evrysdi. This version is specifically written for patients remaining on Evrysdi.


Use the links below to find additional information to enclose in your letter.

FDA approval letter (Follow this link and search by the drug name)

Prescribing Information

Sample coding for Evrysdi