Benlysta Enrollment Form – Download Patient Assistance PDF
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Benlysta Enrollment Form |
Patient Support Program |
08 Pages |
PDF, Fillable PDF |
Benlysta Enrollment Form
It is a required document used to enroll patients in the Benlysta Gateway program, which supports patients with benefits verification, assisting with prior authorization, financial assistance screening, and coordination with specialty pharmacies for Benlysta treatment. This form collects essential details, such as medical information, clinical details, authorization signatures, insurance, and patient information needed to start support services. Download or fill out the form online to begin the process today.
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Benefits of The Benlysta Patient Form
Patient Assistance Program (PAP)
For underinsured or uninsured patients, the form includes fields needed to evaluate eligibility for the Benlysta Patient Assistance Program. If qualified, patients may receive Benylsta at no cost, depending on program guidelines.
Copay Assistance Program
For eligible commercially insured patients, the Benlysta enrollment form allows Benlysta Gateway to review and connect individuals with Benlysta copay assistance programs. These programs may help patients reduce out-of-pocket costs by covering a portion of copay or coinsurance amounts.
Medical And Pharmacy Insurance Benefits
It allows Benlysta Gateway to check a patient’s coverage, including deductible status, out-of-pocket requirements, prior authorization needs, and specialty pharmacy rules. This ensures the provider receives accurate information before treatment begins.
Key Sections of The Benlysta Gateway Enrollment Form
Patient Details
This section includes the patient’s details, such as their name, complete address, date of birth, phone numbers, email, language preferences, and caregiver contact (if applicable).
Insurance Details
It includes fields for uninsured or underinsured patients to determine PAP eligibility.
Prescriber Information
The prescriber section contains their name, practice details, specialty, NPI, tax ID, office contact, and preferred communication method.
Diagnosis & Clinical Information
Requires ICD-10 codes, patient weight, relevant labs, medical history, and confirmation of condition.
Product & Prescription Information
This section covers Benlysta IV and SC options, including dosage, frequency, quantity, refills, and administration site.
Specialty Pharmacy Details
Indicates whether the patient will receive Benlysta at a healthcare facility, infusion centre, or through a specialty pharmacy.
How To Complete The Benlysta Enrollment Form
Patient Information: Provide the patient’s full name, address, date of birth, gender, email, phone & language preferences, and alternate contact details.
Insurance Details: Attach copies of both the front and back of all medical and prescription insurance cards, specifying the insurance provider, insurance phone number, cardholder name, policy number, PCN, and group number. If uninsured, complete the fields required for PAP screening.
Prescriber, Acquisition, And Administration Information: Fill in the prescriber’s name, practice name, specialty, address, office contact details, tax ID, NPI number, and state license number.
Diagnosis & Clinical Information: Add ICD-10 codes, weight, diagnosis history, labs, and any treatment notes needed for insurance and authorization review.
Product Type & Dosage: Choose between Benlysta IV or Benlysta SC, enter the quantity, frequency, and number of refills, and specify the administration site.
Site of Care: Indicate whether the medication will be shipped to an infusion centre, clinic, or specialty pharmacy.
Patient Authorization: The patient must sign the HIPAA section so Benlysta Gateway can request insurance details, coordinate pharmacy service, and process financial assistance.
Prescriber Signature: The prescriber must sign and date the form to authorize enrollment.
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Frequently Asked Questions
What is the purpose of the Benlysta enrollment form?
It is used to enroll a patient in the Benlysta Gateway program. This program helps verify insurance benefits, assist with prior authoization requirements, review eligibility for copay support or Patient Assistance Program (PAP), and coordinates access through a specialty pharmacy.
Who completes the form?
Both the prescriber and the patient complete this form. The prescriber writes clinical, diagnosis, and prescription information, while the patient provides their personal information and signs the authorization section.
Are copies of insurance cards required?
Of course, the form requires copies of both the front and the back of all active medical and pharmacy insurance cards. If the patient has no insurance, the form includes questions needed to determine eligibility for the Benlysta Patient Assistance Program (PAP).
Can uninsured patients apply for assistance?
Yes. The form includes fields for patients without insurance to determine eligibility for the Benlysta PAP.
Can the form be submitted online?
Yes. Providers can submit the form online or by fax.
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