Insurance Benefits Investigations
MySMA Support for Evrysdi can conduct an insurance benefits
investigation (BI) to help you determine if Evrysdi is covered, if
prior authorizations (PAs) are required and if patient assistance
might be needed.
Potential outcomes of an insurance BI:
- Treatment is covered
- PA is required
- Treatment is denied
Once the insurance BI is complete, your Partnership
and Access Liaison (PAL) will walk your patient through his or
her insurance coverage for Evrysdi.
An insurance BI may be initiated once the Evrysdi Start Form is submitted to MySMA.
This form can be downloaded from Forms and Documents.
The completion and submission of coverage- or reimbursement-related
documentation are the responsibility of the patient and health care
provider. Genentech makes no representation or guarantee concerning
coverage or reimbursement for any service or item.
Your Neurological Rare Disease Therapeutic Area Manager (NRD TAM)
or Case Manager (CM) can identify the required prior authorization
forms and documents for submission to the health insurance plan and
provide general resources to help you submit a prior authorization.
Once your practice has submitted a PA, your NRD TAM or CM can follow
up with the payer regarding the PA status. Remember, submitting the PA
is the responsibility of the practice. PA support may be provided once
the Evrysdi Start Form is submitted to MySMA Support for
If your patient's request for a PA is not granted, your NRD TAM or CM can work with you to determine your next steps. You can find more tips like this in Forms and Documents.
The completion and submission of coverage- or reimbursement-related documentation are the responsibility of the patient and health care provider. Genentech makes no representation or guarantee concerning coverage or reimbursement for any service or item.
Evrysdi Start Program
The Evrysdi Start Program may help people who have been prescribed Evrysdi begin treatment as soon as possible by providing short-term, free medication. The Evrysdi Start Program is available for insured people who have been prescribed Evrysdi and are experiencing a delay in insurance approval. Eligible patients may receive up to 2 free 30-day supplies of Evrysdi.
If you believe your patient qualifies for the Evrysdi Start Program,
please submit the completed Evrysdi Start Form and check the Starter
section (Section 6) on page 5 (the Prescriber Service Form). As a
reminder, page 4 of the Start Form (the Patient Consent Form) must
also be completed and submitted to enroll a patient into the Evrysdi
Start Program. For more information, please contact your Evrysdi
The Evrysdi Start Program provides eligible patients who have
experienced an insurance coverage delay with a one-time free supply
of Evrysdi, 60 mg powder for oral solution. There is no purchase of
obligation by virtue of a patient’s receipt of the free supply.
Requests for the Evrysdi Start Program cannot be processed without a
completed and signed 1) Evrysdi Prescriber Service Form and 2)
Patient Consent Form. Patients must be prescribed Evrysdi for an
on-label use. Free product via the Evrysdi Start Program will be
available through Genentech. Neither the prescriber, the pharmacies,
nor any patients receiving free product via the Evrysdi Start
Program may seek reimbursement or credit for all or any part of the
benefit received by the patient through this offer from any insurer,
health plan, or government program. The Evrysdi Start Program cannot
be counted towards any Out-of-Pocket costs under any plan (such as
true Out-of-Pocket cost [TrOOP] under a Medicare Part D prescription
drug plan). The Evrysdi Enrollment Team may notify the patient’s
insurer that the patient is receiving a free supply of product from
the Program. Prescribers may not advertise or otherwise use the
program as a means of promoting their services or Genentech’s
products to patients. This program is void where prohibited by law
and may not be used in or by residents of restricted states, if
applicable. The free supply may not be sold, purchased or traded or
offered for sale, purchase or trade. This program is not a benefit
plan. Genentech reserves the right to discontinue or modify the
terms of this program at any time, without notice.