Evrysdi Starter Program

Funded

About

The Evrysdi Starter Program is designed to assist patients prescribed Evrysdi by offering a temporary supply of the drug product during insurance coverage delays. This program is beneficial for those with private insurance who are experiencing a delay in coverage of at least 5 business days. By providing a free 30-day supply of Evrysdi, with the possibility of a refill in cases of persistent delays, the Evrysdi Starter Program supports patients in starting or maintaining their treatment while addressing insurance issues.

Insurance requirements: Commercially insured

Enrollment Forms

Enrollment Form

Benefits

•2 maximum fills per year

Program Requirements

•Valid only for residents in the US and Puerto Rico

•Enrollment Required: Yes

•Coverage Required: No

•Needs Based: No

•Activation Required: No

Program Details

•Eligible commercially insured patients experiencing a delay in insurance coverage may be able to receive one free 30day supply of Evrysdi

•If the patient experiences a persistent coverage delay, the patient may be eligible for one 30day refill of Evrysdi

•Requests for the Evrysdi Starter Program cannot be processed without a completed and signed Evrysdi Start Form

•Completed form should be faxed to 8333879700 or submitted online at www.evrysdi.com/forms

•For assistance or additional information, call 8333879734

Enrollment Forms

Enrollment Form