Kesimpta Start Form – Download Ofatumumab Enrollment PDF
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Kesimpta Start Form |
Patient Support Program |
03 Pages |
PDF, Fillable PDF |
Kesimpta Start Form
Starting Kesimpta treatment for multiple sclerosis (MS) requires important documentation and benefit verification. The Kesimpta start form is designed to streamline this process, collecting patient, insurance, and prescriber information on a single document to initiate treatment, benefit verification, and connect patients with financial support through Novartis programs, such as $0 Access Card and the Bridge Program. Download, complete, and submit the form today to ensure faster treatment and dedicated patient support.
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Advantages Of Kesimpta Start Form
$0 Access Card Eligibility
The eligible patients may qualify for up to $1,8000 in copay benefits or receive free medication at no cost while insurance coverage is in process.
Enrollment in Patient Support Programs
This form includes access to Alongside Kesimpta, a complete Novartis patient support program with assistance, guidance, and resources.
Bridge to Commercial Coverage
Eligible patients with commercial insurance can get free Kesimpta doses, even if the prior authorization or insurance coverage is pending.
Key Sections of The Alongside Kesimpta Start Form
1- Patient Section
It collects patient details, including name, address, phone number, email, gender, caregiver name (if applicable), and language preferences.
2- Insurance Information Section
This section contains medical and insurance card details, including BIN, PCN number, group number, carrier name, etc.
3- Prescriber Details
It includes the provider’s name, practice name, NPI, state license number, office phone number, fax number, and office address.
4- Prescription Information
Describes diagnosis code, loading and maintenance dose instructions, quantity, SIG, specialty pharmacy, and preferred specialty pharmacy.
5- Program Enrollment
This section contains checkboxes, which allow providers to enroll patients in the Bridge and Copay programs, request assistance, and check eligibility.
6- Provider Enrollment
The provider attests the Kesimpta start form to confirm medical necessity, prescription authorization, and agreement to terms for forwarding and processing.
How To Complete the Kesimpta Patient Form?
Provide Patient Details: Write down the patient details, including first name, last name, gender, email, home/cell phone number, full address, caregiver’s full name, caregiver’s email, and preferred language.
Patient Authorization and Additional Consents: The patient or their legal guardian signs and the effective date of the application form to authorize the patient authorization, allowing Novartis to provide services and assistance.
Insurance Information: Attach the front and back copies of the patient’s medical insurance card and prescription. Also, fill in the cardholder name, insurance carrier, carrier phone number, cardholder ID number, and group number.
Provider Information: Specify the prescriber and office information, including full name, address, city, state, ZIP code, practice name, office contact name, office fax, and phone number.
Prescription Information: Enter the specialty pharmacy name, preferred pharmacy name, ICD-10:35 diagnosis code, shipping preferences, pharmacy prescription, SIG, and quantity for both loading and maintenance doses, and sign up for support programs.
Provider Attestation: The prescriber must sign the Kesimpta start form with the date to validate the prescription and participation.
Submit: Fax the completed form or enroll online at https://covermymeds.health/
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Frequently Asked Questions
Is the $0 Access Card available for everyone?
Not at all. The $0 Access Card is only available for patients with commercial insurance. It is not valid for Medicare, Medicaid, or other government insurance.
What is the Kesimpta start form used for?
The Kesimpta enrollment form is used to initiate treatment with Kesimpta for multiple sclerosis (MS), verify insurance benefits, and enroll eligible patients into Novartis support programs, including Alongside Kesimpta, the $0 Access Card, Bridge to Commercial Coverage, and Novartis Patient Assistance Foundation.
Can a patient receive Kesimpta while waiting for insurance approval?
Of course, eligible commercial insured patients can receive Kesimpta at no cost for up to 12 months through the Bridge to Commercial Coverage program.
How long does it take to process the form?
The processing time can vary, depending on the patient’s diagnosis and application. Submitting a complete and accurate application may reduce delays, though.
What is the Kesimpta copay card, and how does it work?
The Kesimpta copay card is part of $0 Access Program, where eligible commercially insured patients can get up to $18,000 in annual copay assistance. To enroll, the prescriber must check the required box in the Patient Authorization section of the form.
Related Forms
The Briumvi Start Form helps patients with relapsing MS initiate treatment with Briumvi, a CD20-targeting therapy similar to Kesimpta.
Relapsing MS patients can use the Ocrevus Start Form to start treatment and connect with support programs.