Evrysdi Case Managers
A Case Manager may assist during your patient's treatment with access and reimbursement.
Available Financial Assistance Options
The Evrysdi Co-pay Program
If eligible commercially insured patients need assistance with their drug out-of-pocket costs, the Evrysdi Co-pay Program may be able to help.
To get started, call (833) 387-9734 or visit EvrysdiCopay.com.
Eligibility criteria and benefit limits apply. Not valid for patients whose prescriptions are reimbursed under any federal or state government programs to pay for their Genentech medicine. Patients must be taking the Genentech medicine for an FDA-approved indication. Please visit the Co-pay Program website for the full list of Terms and Conditions.
Referrals to Independent Co-pay Assistance Foundations
For eligible patients with commercial or public health insurance, a Case Manager offers referrals to independent co-pay assistance foundations that may be able to help.
Independent co-pay assistance foundations have their own rules for eligibility. Genentech has no involvement or influence in independent foundation decision-making or eligibility criteria and does not know if a foundation will be able to help your patient. We can only refer your patient to a foundation that supports their disease state. This information is provided as a resource for you. Genentech does not endorse or show preference for any particular foundation. The foundations in this list may not be the only ones that might be able to help your patient.
The Genentech Patient Foundation
If patients don’t have health insurance coverage or have financial concerns and meet eligibility criteria, they may be able to get Genentech medicine at no cost from the Genentech Patient Foundation.
Call (888) 941-3331 to speak with a live Foundation Specialist. We offer support in many different languages.
To be eligible for free Genentech medicine from the Genentech Patient Foundation, insured patients who have coverage for their medicine should try to pursue other forms of financial assistance, if available, and meet certain income requirements. Uninsured patients and insured patients without coverage for their medicine must meet a different set of income requirements. Genentech reserves the right to modify or discontinue the program at any time and to verify the accuracy of information submitted.
Reimbursement Support
Evrysdi Sample Coding
This coding information may assist you as you complete the payer forms for Evrysdi. These resources are provided for informational purposes only. Please visit CMS.gov or other payers’ websites to obtain additional guidance on their processes related to billing and coding for single-use vials and wastage.
Correct coding is the responsibility of the provider submitting the claim for the item or service. Please check with the payer to verify codes and special billing requirements. Genentech does not make any representation or guarantee concerning reimbursement or coverage for any item or service.
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Complete and submit a form electronically.
Appeals
If your patient’s health insurance plan has issued a denial, your Neurological Rare Disease Account Manager (NRD AM) or Case Manager (CM) can provide resources as you prepare an appeal submission, as per your patient’s plan requirements.
If a plan issues a denial:
The denial should be reviewed, along with the health insurance plan’s guidelines, to determine what to include in your patient’s appeal submission
Your NRD AM or CM has local payer coverage expertise and can help you determine specific requirements for your patient
A sample appeal letter and additional considerations are available in Resources.
Appeals cannot be completed or submitted by MySMA Support for Evrysdi on your behalf.
Coverage Resources
Insurance Benefits Investigations
MySMA Support for Evrysdi can conduct a benefits investigation (BI) to help you determine if Evrysdi is covered, if prior authorizations (PAs) are required, which specialty pharmacy (SP) the health insurance plan prefers and if financial assistance might be needed.
Potential outcomes of a 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 Support.
Forms can be downloaded from Enrollment.
A sample appeal letter and additional considerations are available in Resources.
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.
Prior Authorization
Your Neurological Rare Disease Account Manager (NRD AM) or Case Manager (CM) can help you identify if a prior authorization (PA) is necessary and offer resources as you request it for your patient. Once your practice has submitted a PA, your NRD AM 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 Evrysdi.
Forms can be downloaded from Enrollment.
If your patient’s request for a PA is not granted, your NRD AM or CM can work with you to determine your next steps. You can find more tips like this in Resources.
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 shipments 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 6 (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 representative.
Forms can be downloaded from Enrollment.
Subject to eligibility requirements and terms and conditions. This program is void where prohibited by law and may not be used in or by residents of restricted states, if applicable.
Enrollment
To enroll in Genentech patient support services, both you and your patient will need to complete the required forms.
For Patients: (choose one)
- Patient Consent Form - English
- Patient Consent Form - Spanish
For Providers: (choose one)
- Evrysdi Start Form (to enroll patients in MySMA Support)
- Prescriber Foundation Form (to enroll eligible patients into the Genentech Patient Foundation only)
Both forms must be received before Genentech can begin helping your patient. Only the information requested on these forms is required. Providing unrequested documents or information will delay processing.
Distribution
Specialty Pharmacies
A specialty pharmacy (SP)* prepares and ships Evrysdi directly to patients each month. Although the SP is not a part of Genentech, it is an important part of the MySMA Support team.
The SP will call the patient or caregiver to welcome them to the program and to schedule delivery times that work best for them. Remind the patient or caregiver to answer calls from the SP to prevent any delays in treatment.
| Pharmacy | Telephone | Fax | Web Orders |
|---|---|---|---|
| Accredo Specialty Pharmacy | 855-525-7995 | 800-216-6938 | www.accredo.com |
| Special Care Pharmacy (Puerto Rico Only) | 787-783-8579 | 787-783-2951 | specialcarepr.com |
Note: Pharmacies primarily serving the patients of particular health systems or health plans are not included in this list.
Genentech does not influence or advocate the use of any one specialty distributor or SP. We make no representation or guarantee of service or coverage of any item.
*Specialty pharmacies are not part of Genentech and maintain independence in their operations and in their role as a health care provider.