Otezla Enrollment Form – Download PDF for Amgen SupportPlus
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Otezla Enrollment Form |
Patient Support Program |
08 Pages |
PDF, Fillable PDF |
Otezla Enrollment Form
The Otezla enrollment form is a document for patients starting treatment with Otezla (apremilast), ensuring your healthcare provider, specialty pharmacy, and support programs have all the required information that is needed to process your prescription, verify benefits, and enroll you in assistance programs. Access, fill, and submit the form now for free.
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Advantages Of Otezla Patient Enrollment Form
Enrolls in Otezla SupportPlus
The form allows eligible patients to access Otezla patient support services, including copay assistance and help with benefit verification.
Enrollment in The Bridge Program
If the eligible patient faces coverage delays, the form lets them opt into the Bridge Program for temporary medication at no cost.
Details Titration Starter Pack
The Otezla patient assistance form allows prescribers to select an appropriate titration starter pack, maintenance dosage, and refill quantities.
Complete Patient Information
It collects all necessary information, including legal name, address, gender, phone number, diagnosis, and medication, ensuring accurate identification and prescription.
Clinical Diagnosis
The healthcare provider can list the patient’s condition using ICD-10-CM codes, affected areas, percentage of body surface area affected, previous and current treatments, medical justification, and medical necessity.
Easier Submission
The completed Otezla form can be faxed along with attached copies of the insurance card to the selected specialty pharmacy or Otezla SupportPlus, making the enrollment and prescription process smoother.
Key Sections of the Otezla Start Form PDF
1- Patient Information
Enter the patient’s name, gender, address, home phone number, mobile number, email address, last 4 digits of SSN, and date of birth.
2- Insurance Information
Describe the insurance details, including primary insurance name, policy number, group number, insurance phone, policyholder name, secondary insurance, pharmacy benefit manager (PBM), member ID, group ID, and BIN. Also, attach your insurance card and pharmacy benefit card. At the end of this section, the patient or their representative must sign, indicating the effective date.
3- Diagnosis and Clinical Information
The healthcare provider must describe the patient’s primary diagnosis using ICD-10-CM codes, specify the affected areas (hands, arms, nails, trunk, feet, scalp, or legs), and document any previous or current treatment and medication.
4- Prescription For Otezla
The section contains information, including dosage, starter packs, bridge therapy, maintenance plans, additional details, and special instructions.
5- Prescriber Information
Describe the prescriber’s first and last name, address, facility name, office fax or phone number, NPI, Tax ID number, DEA number, state license number, and signature of the prescriber and the prescribing physician.
How To Fill Out Otezla Start Form?
Access the Form: Download or access the online and fillable Otezla start form.
Enter Patient’s Details: Enter the patient’s information, including name, gender, address, date of birth, phone number, and email.
Insurance Details: Describe the primary insurance, policy ID, group number, policyholder name, member ID, PBM, BIN, etc.
Other Information: Share the Otezla enrollment form with your physician and prescriber. They will complete their part, including primary diagnosis, affected areas, dosage details, medical history, and special notes.
Signature: The patient, prescriber, and supervising physician have to sign the form to verify that the information provided by the patient is accurate.
Submit: Download or submit the form.
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Frequently Asked Questions
What is the Otezla enrollment (start) form?
The START form is a document for patients starting treatment with Otezla or enrolling in support services, such as the Copay Program or Bridge Program. It collects all necessary information regarding the patient, insurance, clinical details, diagnosis, and prescription.
What is the Bridge Program?
It provides temporary medication to eligible patients at no cost in the event of insurance coverage delays.
Can I enroll in the copay program through this form?
Of course, if you are commercially insured, you can indicate your interest in the Otezla Copay Program by selecting a checkbox in the form.
Can someone sign the form on behalf of the patient?
If the patient cannot sign, the representative or the patient’s authorized person may sign the HIPAA authorization section, indicating their authority to act on behalf of the patient.
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