Adbry Enrollment Form PDF – Start Tralokinumab Patient Support
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Adbry Enrollment Form |
Patient Support Program |
03 Pages |
PDF, Fillable PDF |
Adbry Enrollment Form
The Adbry enrollment form is a document used to enroll patients in the Adbry Advocate program. It allows patients to access Adbry (tralokinumab) for the treatment of dermatitis. Additionally, the form helps your healthcare provider and LEO Pharma to coordinate your specialty pharmacy services, verify insurance, and access the free product program. Download the fillable PDF now or complete the form online and start your medication and financial assistance without delays.
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Advantages Of Adbry Enrollment and Prescription Form
Insurance Benefit Verification
By providing accurate insurance details and attaching both sides of your insurance cards, the program verifies your medical coverage and pharmacy benefits, ensuring what is or is not covered.
Copay Support Program Access
The form enrolls eligible patients in the Adbry copay support program, helping reduce your out-of-pocket cost if you have commercial insurance.
Rapid Access Program Enrollment
If you are eligible and have commercial insurance, you can receive an initial dose of Adbry within 48 hours through the Adbry rapid access program.
Dedicated Patient Support
Once enrolled, the patient will get access to the Adbry Advocate Program, which provides personalised and dedicated support and assistance with their ongoing treatment journey.
Specialty Pharmacy Coordination
The form allows patients to choose their specialty pharmacy to process and deliver their medication. The prescriber can select or indicate the desired specialty pharmacy on the form.
Secure Authorization
By signing the Adbry patient form , you ensure that your personal, medical, and insurance information is shared securely. It aligns with HIPAA and privacy laws.
Key Sections of the Adbry Enrollment Form
1- Patient Information
Enter the patient’s name, gender, date of birth, address, city, state, zip code, phone number (cell or home), email, and permission to leave voicemail. After filling out the patient’s information, select the option to consent to receive voicemail, calls, or text messages related to treatment and support programs, and sign the form with the current date.
2- Insurance Information
The section contains the insurance details, including primary pharmacy insurance, primary medical insurance, policyholder name, group number, phone number, PCN number, BIN, member ID, and medical ID number. Also, attach the patient’s insurance card.
3- Diagnosis Details
Describe the patient’s diagnosis, such as Atopic Dermatitis or other, using the ICD-10 code, date of diagnosis, prior therapies, current therapies, and medication allergies.
4- Prescriber Information
It includes the prescriber’s first and last name, NPI number, state license number, office name, office phone number, office fax number, address, city, state, and zip code.
5- Adbry Advocate Program
This section describes what support services the patient needs, such as copay support, Adbry rapid access program, Adbry bridge care program, etc.
6- Prescription Details
It describes the Adbry prescription, based on the patient’s age and treatment plan.
7- Prescriber Certification
It requires the prescriber’s signature to certify that the provided information is accurate and the prescription is medically necessary.
How To Fill Out Adbry Patient Form PDF?
Access the Form: Download or access the online fillable 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, PCN, BIN, etc.
Other Information: Share the Adbry enrollment form with your healthcare provider and prescriber. They will complete their part, including primary diagnosis, dosage details, specialty pharmacy information, and details on previous and current therapies.
Signature: The patient and prescriber have to sign the form to authorize and verify that the information provided by the patient is accurate and that the medication is necessary.
Submit: Download or submit the Adbry Enrollment Form.
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Frequently Asked Questions
What is the Adbry enrollment form, and why do I need it?
It is a document used to authorize your healthcare provider, specialty pharmacy, and LEO Pharma to share your personal, medical, and insurance information and coordinate your treatment. It also ensures your insurance benefit verification, prior authorization, and enrollment in support programs.
How long is the Patient Authorization valid?
The Patient Authorization remains valid for five years from the date of signing unless you revoke it sooner.
Do I choose the specialty pharmacy that fills my prescription?
Of course, you or your prescriber can choose an in-network specialty pharmacy from the list provided in the Adbry Specialty Pharmacy section.
What happens if my insurance denies coverage?
If your insurance delays coverage, you can still get the free medication temporarily under the Adbry Bridge Care Program.
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