Tyvaso Enrollment Form – United Therapeutics Patient Assistance
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Tyvaso Enrollment Form |
Patient Support Program |
07 Pages |
PDF, Fillable PDF |
Tyvaso Enrollment Form
If Tyvaso or Tyvaso DPI has been prescribed for pulmonary arterial hypertension (PAH) or PH-ILD, timely and accurate submission of the Tyvaso enrollment form is mandatory. It allows the prescription to be processed, insurance benefits to be reviewed, and patient support services to begin. Also, this form assesses for financial assistance and access to the StartRx Program when coverage decisions are delayed. Ready to proceed? Download the fillable form, complete all required fields, attach documents, and fax it to avoid delays in treatment approval and medication access.
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Benefits of the Tyvaso Enrollment Form
Faster Access
The form allows the prescription to be processed directly to the appropriate specialty pharmacy, reducing processing time.
Insurance Verification Support
Once submitted, the support team reviews both medical and pharmacy benefits. This helps determine coverage requirements, prior authorisation needs, and potential out-of-pocket costs before therapy starts.
Temporary Medication Access
If coverage determination is delayed, eligible patients may qualify for a limited supply of medication under the StartRx Program, helping prevent interruptions or delays in initiating therapy.
Key Sections of the Tyvaso Enrollment Form
Referral Cover Section
The first section of the form includes necessary details, such as facility name, prescriber information, and the prescribed product. It also lets you choose the preferred specialty pharmacy.
Patient Details
It specifies the patient’s legal name, date of birth, contact details, complete address, and shipping address (if different).
Insurance Section
The section contains both medical and prescription insurance details, including subscriber IDs, policyholder, and group numbers.
Clinical History
Specifies ICD-10 diagnosis codes for PH-ILD or PAH, current medications, allergies, and NYHA functional classes.
How to Complete the Tyvaso Enrollment Fillable PDF Form?
Referral Cover Sheet: Fill in the facility name, prescriber details, and the product prescribed. Confirm the preferred speciality pharmacy if the payer does not mandate one.
Patient Details: Write the complete patient name, date of birth, gender, address, phone number, and caregiver details. Also, indicate the patient’s therapy status for Tyvaso or Tyvaso DPI.
Prescriber Information: Provide the prescriber’s name, office or institution name, office address, phone number and fax numbers, contact email, state license number, and NPI.
Insurance Information: Fill in the primary prescription and medical insurance details, including insurance name, subscriber ID numbers, group numbers, and phone numbers.
Preferred Specialty Pharmacy: Choose the preferred specialty pharmacy, i.e., CVS Specialty Pharmacy or Accredo Health Group, Inc.
Patient’s Clinical History: Choose the appropriate ICD-10 diagnosis codes for PH and ILD. Also write the patient’s height, weight, and any known allergies (if any).
Prescription Details: The physician will choose the required target dose, number of refills, frequency, and maintenance dose.
Signatures: The patient or their legal representative must sign and date the form.
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Frequently Asked Questions
Can financial assistance be guaranteed?
No. Financial assistance is based on eligibility criteria, including insurance status and income verification. Enrollment in the program allows evaluation for assistance, but approval is not automatic.
Can the patient withdraw consent after enrolling?
Of course, the patient may revoke authorization or withdraw from United Therapeutics Cares at any time by providing written notice as outlined in the form. Withdrawal does not affect previous disclosures made before revocation.
Who completes the Tyvaso enrollment form?
Both the prescriber and the ptient completes the form. The prescriber fills in the medical and prescription sections. While the patient completes the consent and authorization sections.
What documents are required?
Insurance cards and relevant clinical documentation, such as right heart catheterisation reports or CT scans for PH-ILD patients.
What is the StartRx Program?
It provides a limited supply of medication for eligible patients experiencing prior authorization delays.