Vyepti Start Form – Download Fillable Migraine Enrollment PDF
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Vyepti Start Form |
Migraine Treatment |
04 Pages |
PDF, Fillable PDF |
Vyepti Start Form
The Vyepti Start Form contains important information, such as patient demographics, insurance details, carrier information, clinical and prescription instructions, specialty pharmacy, and infusion site preferences. Additionally, the form is used by healthcare providers to begin Vyepti (Eptinezumab-jjmr) therapy, allowing patients to access support programs, such as nurse support, copay programs, benefits verification, and prior authorization access. If you’re a healthcare provider handling Vyepti initiation, having the correct and updated start form ensures accurate and smooth processing. To ensure full patient support and faster processing, download or fill out the form online.
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Advantages Of Vyepti Start Form PDF
Nursing and Infusion Supply Orders
The forms allow providers to request skilled nursing visits and supplies, ensuring the patient is getting safe, accurate, and properly administered infusions.
Access to Vyepti Connect Nurse Support
Once enrolled, the patients will automatically be eligible to get educational and support through Vyepti Connect Nurse Support, available from Monday to Friday.
Optional Enrollment
The Vyepti start form supports patient access to financial assistance through the Vyepti Connect Copay Assistance Program for eligible and commercially insured patients, reducing treatment costs.
Key Sections of the Vyepti Enrollment Form
1- Patient Information
The first section describes the patient’s date of birth, full name, last name, gender, full address (including city, state, ZIP code), phone number, relationship to patient, and emergency contact details.
2- Prescriber Information
It includes the prescriber’s details, such as first and last name, specialty, NPI, PTAN, tax ID, office name, office address, city, state, office contact number, and fax number.
3- Medical Insurance Details
This section includes medical and insurance information, such as insurer name, phone number, member ID, group ID, policyholder’s name, date of birth, and relationship to patient. Additionally, it also describes the pharmacy insurance, including insurance name, policy ID, group ID, BIN, and PCN.
4- Infusion Provider Details
It describes whether the infusion provider is different from the prescriber’s office. This section requires the infusion site name, address, city, state, ZIP code, contact name, phone number, tax ID, etc.
5- Clinical Information
Includes the selection of dosage, ICD-10 diagnosis code, migraine start date, number of headache days per month, last treatment date, anticipated infusion date, allergy history, and previous migraine medication.
6- Prescription and Administration Details
This part of the form is only required when sending the form to a specialty pharmacy or infusion provider. It contains information on the special instructions for infusion preparation, administration and nursing orders, supply requirements, dosage selection, quantity, refills, preferred specialty pharmacy, nursing support needs, and the SIG.
7- Vyepti Connect Program Selections
The Vyepti connect program selection section allows the provider to opt-in to notifications, such as final coverage status, upcoming infusion reminders, and apply these preferences for all patients enrolled by the provider.
8- Prescriber Authorization
The prescriber should complete this section to certify that the provided information is accurate and that Vyepti treatment is necessary. This section also requires the prescriber’s name, signature, and date.
9- Patient Authorization
The section must be filled out by the patient themselves or the authorized representative to allow permissions to share the patient’s health information with Lundbeck and Vyepti Connect for support program purposes.
10- Copay Assistance Eligibility Section
It allows the commercially insured patients to access the Vyepti Connect Copay Assistance Program. There are five screening questions that the patient has to answer.
How To Fill Out Vyepti Connect Copay Assistance Program Form?
Access the Form: Download or access the Vyepti start form.
Patient & Insurance Information: Provide the insurance and patient’s details, including first and last name, date of birth, address, contact number, insurer’s name, member ID, tax ID, etc. Also, attach both copies (front and back ) of insurance cards.
Prescriber Details: Describe the prescriber’s information, including the provider’s name, NPI, clinic address, and contact details.
Clinical & Prescription Details: Write the patient’s accurate diagnosis using ICD-10 code for episodic or chronic migraine, infusion dose, etc.
Choose Support Services: Check the box to request the support services, such as benefits verification, prior authorization support, copay assistance, and patient enrollment in Vyepti Connect.
Specialty Pharmacy Details: List the preferred specialty pharmacy (if any). Otherwise, let the support team assign one.
Patient Authorization: The patient or their authorized representative must review and sign the HIPAA section to authorize consent for benefit investigation and use of support services.
Review, Sign and Submit: The final review must be from the healthcare provider with a signature to certify the request for treatment and support services.
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Frequently Asked Questions
What is the Vyepti start form used for?
This form is officially known as the Vyepti Connect Enrollment Form, and is used to initiate Vyepti treatment and enroll patients in support services, including benefits verification, prior authorization, infusion coordination, nurse support, and financial assistance.
Can I receive infusions at home?
Of course, this form allows providers to choose from multiple infusion sites, including a physician’s office, a hospital, an infusion centre, and home infusion.
How does the copay assistance program work?
The eligible commercially insured patients may qualify for the Vyepti Connect Copay Assistance Program, potentially paying $0 per infusion. This program covers medication and up to $200 in administration costs per treatment.
Is there any dedicated section for prior migraine treatment history?
Yes, there is a section for prior migraine medication and treatment details, which support payer review and medical necessity for Vyepti treatment.
How long is the patient authorization valid?
It is valid for ten years from the date of signature. To cancel it earlier, the patient or authorized representative has to submit a written application to the program’s privacy office.
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