Sotyktu Enrollment Form Download – Printable PDF for Patients
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Sotyktu Enrollment Form |
Patient Support Program |
04 Pages |
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Sotyktu Enrollment Form
The Sotyktu enrollment form is an important document used to collect necessary information related to the patient, prescriber, and insurance. Additionally, this form allows patients to access Sotyktu 360 Support, copay assistance, and the Bridge program. By completing this form with required information from both the patient and the prescriber, individuals can receive financial support, personalized support, medication guidance, and help with insurance verification. Download the PDF form now and fill it out with your healthcare provider to get timely access to the treatment.
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Benefits of The Sotyktu Enrollment Form
Eligibility Copay Card Savings
A commercially insured patient may qualify for the co-pay card, which reduces monthly out-of-pocket costs. It makes long-term treatment more affordable and manageable.
Sotyktu Patient Education & Ongoing
Once enrolled, the patients receive educational support related to their condition, treatment guidance, medication reminders, and program updates. This support encourages better adherence and empowers patients with knowledge about their therapy.
Bridge Program Access
If approval insurance is delayed or denied, the Bridge program provides temporary access to medication, ensuring that patients can start treatment without any delay while appeals or authorizations are pending.
Key Sections of The Sotyktu 360 Enrollment Form
1- Patient Information
It gathers basic details of the patient, such as name, date of birth, gender, address, contact details, and language preferences.
2- Prescriber Information
The “Section-B” describes the prescriber’s name, NPI, license number, clinic details, and best contact time.
3- Clinical Information
This section records ICD-10 diagnosis codes, prior therapies, and any allergies.
4- Prescription Section
It specifies the medication, whether it is for maintenance or bridge access, frequency, refills, and preferred pharmacy.
5- Prescriber Authorization
This section requires the prescriber’s signature and date to authorize the prescription.
6- Patient Authorization and Agreement
It requires a patient’s signature to allow insurance checks, program enrollment, and communication.
How To Complete The Sotyktu Enrollment Form PDF?
Patient Details: Fill in the patient’s full name, date of birth, street address, state, ZIP code, city, email address, contact details, gender, and language preferences.
Prescription Insurance Information: Describe the primary pharmacy carrier, pharmacy member ID, group ID, BIN number, etc. Also, attach front and back copies of insurance card(s) and specify the primary medical insurance carrier and policy ID.
Healthcare Provider Information: Write the prescriber’s name, NPI number, state license number, practice name, fax & phone number, complete address, and primary office contact name and details.
Clinical Information: Indicate the Plaque psoriasis ICD-10 codes, date of diagnosis, prior therapies, and allergies (if any).
Prescription Information: Choose the appropriate options, such as maintenance prescription or bridge program prescription. Additionally, indicate the medication frequency, supply quantity, refills, and pharmacy preferences.
Prescriber Authorization: The prescriber must sign and date the form to certify medical necessity.
Patient Authorization: The patient or their legal representative must sign and date the form, specifying their name, email address, and the representative’s relationship to the patient. Choose the consent box to receive promotional emails and text messages.
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Frequently Asked Questions
What is the Sotyktu enrollment form?
The form is used to enroll patients in SOTYKT 360 support services, including co-pay assistance, the Bridge program, benefits verification, and personalized patient support.
What is the co-pay assistance program, and how does it work?
Commercially insured eligible patients may qualify for the Co-Pay Card, which can reduce out-of-pocket costs, covering eligible expenses not paid by insurance. The patients with government insurance are not eligible for this program.
How long does the Bridge Program last?
The Bridge Program can provide support for up to 24 months if prior authorization is delayed or denied.
Can Medicaid or Medicare patients enroll in the program?
The patients with government-funded insurance, such as Medicare, Medicaid, VA, or Tricare, are not eligible for copay or Bridge assistance.
How do the patients receive their medication after enrollment?
Once the form is processed and benefits are confirmed, the prescription is sent to the chosen specialty pharmacy. The pharmacy will contact the patient to arrange delivery.
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