Fasenra Enrollment Form – Download PDF for Patient Assistance
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Fasenra Enrollment Form |
Patient Support Program |
05 Pages |
PDF, Fillable PDF |
Fasenra Enrollment Form
Initiating treatment with Fasenra can involve several steps and prescription coordination. That’s why the Fasenra enrollment form is designed to help patients access support services, such as benefit verifications, prior authorization, specialty pharmacy referrals, prescription triage, and financial assistance provided by AstraZeneca’s Access 360 Program. By submitting this form accurately ensure faster access to medication and personalized support. Download, fill it out, and submit the form today to avoid delays in care.
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Advantages Of AstraZeneca Access 360 Enrollment Form
Buy & Bill Coordination
The Fasenra enrollment form allows providers to request Fasenra through the Buy & Bill pathway, giving flexibility in how medication is obtained.
Financial Assistance Pathways
Patients waiting for insurance, without coverage, or those on Medicare who cannot afford the Fasenra may be referred to the AZ&Me saving programs.
Insurance Authorization Tracking
The form tracks prior authorization requests and assists with appeals or follow-up if coverage is delayed.
Key Sections of The Fasenra Enrollment Form PDF
1- Access 360 Services
The first section of the Fasenra enrollment form allows providers to choose required specific support services, such as benefits check, specialty pharmacy triage, free limited supply, etc.
2- Patient Information
This part contains patient details, including name, contact details, alternate contact, and communication preferences.
3- Patient Authorization
A consent section to authorize for sharing of medical information with AstraZeneca for coordination support services.
4- Insurance Details
This section lists primary and secondary insurance details, including carrier name, contact, and BIN details.
5- Prescriber & Practice Section
It includes prescriber and practice details, such as NPI, office details, tax ID, and contact information.
6- Clinical and Diagnosis Information
The section specifies EGPA or medical diagnosis code, corticosteroid dependency, corticosteroid usage, most recent test date, product formulation, dosing schedule, and refill instructions.
7- Free Limited Supply Request
It allows prescribers to request a limited supply if the patient needs it while insurance approval is pending.
How To Complete the Fasenra 360 Enrollment Form?
Select Requested Services: Choose the requested services check boxes, including benefits verification, specialty pharmacy, buy & bill, free limited supply, etc.
Patient Information: Provide patient details, including their full name, date of birth, gender, phone number, address, and preferred language.
Patient Authorization: Sign the patient authorization, allowing AstraZeneca to access medical records.
Insurance Information: Specify the patient coverage, such as commercial, private, Medicare, Medicaid, or Tricare. Also, provide primary medical insurance provider name, phone number, cardholder name, policy number, group number, BIN, and PCN, attaching copies of the front and back sides of insurance cards.
Prescriber Information: The prescriber must provide their information, including complete name, practice name, practice phone number, address, Medicare provider number (PTAN), NPI, group NPI number, tax ID number, staff name, etc.
Clinical Information: Provide clinical details, such as eosinophil count, corticosteroid usage, most recent test date, appropriate diagnosis code (J45.50, J45.51, or J82.83) for asthma condition, and other required necessities.
Prescription Information: Indicate the correct Fasenra formulation, age-based dosage, frequency, and refills. Additionally, mention if the patient has known allergies, last injection date, dose instructions, etc.
Prescriber Signature: Sign and date the authorization to confirm the prescription is medically necessary and all provided information is accurate.
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Frequently Asked Questions
What services can be requested through the form?
The form lets request services like insurance authorization tracking, specialty pharmacy triage, appeals support, benefits investigation, and free limited supply (FLS) if the coverage is denied or delayed.
What is the purpose of the Fasenra enrollment form?
This form is used to enroll patients in the AstraZeneca Access 360 program, which provides dedicated services, such as benefit investigation, insurance authorization follow-up, specialty pharmacy referrals, financial assistance, and limited free supply to eligible patients.
Can uninsured patients apply for Fasenra?
Of course, the patients waiting for approval can still apply for Fasenra. They may be referred to AstraZeneca’s AZ&Me program for medication assistance.
How long is the patient authorization valid?
It remains valid for two years from the date of signing the application.
Do I need to attach insurance cards with the form?
Yes, this form requires copies of both front and back of medical and pharmacy insurance cards.
What is the Fasenra copay card?
It is a saving program that helps eligible commercially insured patients reduce their out-of-pocket costs for Fasenra. This program is not valid for patients with government-funded insurance, such as Medicare, Medicaid, or Tricare.
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