ACTEMRA® (tocilizumab)
ALECENSA® (alectinib)
Avastin® (bevacizumab)
COTELLIC® (cobimetinib)
ENSPRYNG™ (satralizumab-mwge)
Erivedge® (vismodegib)
Esbriet® (pirfenidone)
Evrysdi® (risdiplam)
GAVRETO® (pralsetinib)
GAZYVA® (obinutuzumab)
HEMLIBRA® (emicizumab-kxwh)
Herceptin® (trastuzumab)
Herceptin HYLECTA™ (trastuzumab and hyaluronidase-oysk)
KADCYLA® (ado-trastuzumab emtansine)
LUCENTIS® (ranibizumab injection)
OCREVUS® (ocrelizumab)
PERJETA® (pertuzumab)
PHESGO™ (pertuzumab, trastuzumab, and hyaluronidase-zzxf)
POLIVY® (polatuzumab vedotin-piiq)
Pulmozyme® (dornase alfa) Inhalation Solution
Rituxan® (rituximab) for Rheumatoid Arthritis (RA)
RITUXAN® (rituximab) for Oncology
Rituxan® (rituximab) for Granulomatosis with Polyangiitis (GPA), Microscopic Polyangiitis (MPA) or Pemphigus Vulgaris (PV)
RITUXAN HYCELA® (rituximab/hyaluronidase human)
ROZLYTREK® (entrectinib)
SUSVIMO™ (ranibizumab injection)
TECENTRIQ® (atezolizumab)
VABYSMO™ (faricimab-svoa)
VENCLEXTA® (venetoclax tablets)
XELODA® (capecitabine)
XOLAIR® (omalizumab) for subcutaneous use
ZELBORAF® (vemurafenib)
Oncology
Ophthalmology
Rheumatology
To contact MySMA Support call (833) 387-9734 (9 a.m.–8 p.m. ET, Monday through Friday).
Quickly Enroll in MySMA Support brochure
The Quickly Enroll in MySMA Support brochure provides a step-by-step overview of using eSubmit (also known as Quick Enroll) to enroll patients in MySMA Support.
Enrolling Patients in MySMA Support by Genentech brochure
The Enrolling Patients in MySMA Support brochure provides tips for completing the Evrysdi Start Form and includes important information about the MySMA Support team.
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 6), which is to be completed by the health care provider. Both pages must be completed for enrollment. To use Quick Enroll for the Evrysdi Start Form, select eSubmit.
-
Evrysdi Start Form
The Evrysdi Start Form is the single form required for enrollment in MySMA Support. It must be completed by both the provider and the patient.
The provider section includes patient, insurance and prescription information used when MySMA Support contacts a patient’s health insurance plan to determine his or her coverage.
The patient section is signed and dated by the patient, giving written permission for MySMA Support to work with you and his or her health insurance plan. -
Patient consent section of the Evrysdi Start Form
Electronically submit or download the patient section of the Evrysdi Start Form. -
Spanish form: Formulario de Inicio de Evrysdi
A version of the Evrysdi Start Form in Spanish.
-
Complete and submit a form electronically.
Other Important Documents
A Road Map for Helping Patients: How MySMA Support Can Help You and Your Patients
This guide provides an overview of how MySMA Support may help patients who have been prescribed Evrysdi access their medicine as well as tips on navigating health insurance coverage and appeals processes.
Sample Letter of Medical Necessity or Appeal Template
This sample letter provides examples of information that may be required when completing a letter of medical necessity or an appeal letter. You may use this template as a guide to help you draft a letter of medical necessity or an appeal letter.
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)
For assistance, call (877) GENENTECH/(877) 436-3683
6 a.m.–5 p.m. PT, Monday through Friday
To enroll in MySMA Support, complete and submit the Evrysdi Start Form