Vumerity Start Form – Biogen Support Enrollment & Prior Authorization
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Vumerity Start Form |
Patient Support Program |
04 Pages |
PDF, Fillable PDF |
Vumerity Start Form
Initiating treatment with Vumerity requires accurate documentation. The Vumerity start form is used to gather all necessary patient information, secure authorization, verify insurance coverage, and connect eligible patients to Biogen support services, including copay assistance, prescription coordination, and home delivery. The patient and the prescriber must complete it accurately to avoid unnecessary delays in starting treatment. To move forward, fill it out online or download and complete the form today, and submit.
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Advantages Of Vumerity Start Form
Home Delivery Support
Once completed, the form supports direct home delivery. The patient can get their medications at their preferred address through an authorized specialty pharmacy, reducing in-person pharmacy visits.
Access to Biogen Support Services
By signing and authorizing the Vumerity form, the patients can be enrolled in Biogen’s Support Services, such as dedicated support, ongoing treatment coordination, and educational resources.
HIPAA Compliance
The form ensures compliance with legal and privacy requirements, enabling Biogen to use patients’ health information for treatment coordination.
Key Sections of The Vumerity Start Form PDF
1- Patient Information
This section includes the patient’s personal details, contact numbers, preferred language, gender, and date of birth.
2- Authorization
The authorization to share health information section allows Biogen to access your health information (PHI) for coordination and support.
3- Patient Services Authorization
It allows Biogen to provide services, such as financial assistance programs, treatment coordination, and educational resources.
4- Marketing Authorization
An optional section to consent for Biogen to contact the patient with their product updates, services, and programs.
5- Government Payer Attestation
This section confirms whether the patient is receiving any federally funded health insurance.
6- Pharmacy Benefit Section
It describes insurance coverage, pharmacy benefits, and specialty pharmacy preferences.
7- Medical Necessity
This section contains prior treatment, allergies, diagnosis, and prescription.
8- QuickStart Program Authorization
The commercially insured and eligible patients may get up to 4 months of Vumerity at no cost while their insurance coverage is being processed.
How To Complete the Vumerity Patient Enrollment Form?
Patient Authorization: Review and sign the patient consent from the sections A, B, C, and D to authorize the sharing of your health information and agree to the terms.
Patient Information: Fill out patient information, including gender, date of birth, complete name, address, city, state, ZIP code, email address, and contact details.
Patient Services Authorization: Sign the required authorization services, such as patient service authorization, health information authorization, marketing authorization, and check the government payer attestation boxes.
Insurance Details: Provide copies of both sides of your medical and prescription cards and insurance information, including primary insurance, policy number, group number, insurance company phone number, and policyholder name.
Pharmacy Benefit Information: Attach copies of both sides of the patient’s pharmacy benefit cards. Also, describe PBM name, BIN, PCN, group number, ID number, policyholder name, and PBM phone number. Additionally, check the boxes if the patient has a secondary coverage or has no coverage.
Prescription and Medical Information: The healthcare provider should fill it out. They must describe the primary diagnosis with an ICD-10 code, current and prior therapies, allergies, and dosage details.
QuickStart Program: Check the box to avail Biogen’s QuickStart program, where the patient will receive 4 months of Vumerity at no cost until their prescription coverage is secured.
Prescriber Information: Write the prescriber’s details, including name, address, phone number, fax number, clinical or hospital affiliation, tax ID, state license number, NPI number, and personal and office contact details.
Prescriber Authorization: Sign and date the form for authorization of the provided information, diagnosis, and treatment.
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Frequently Asked Questions
Is signing all authorization sections mandatory?
Not all authorization sections are required to be signed. But signing sections A and B is strongly recommended for faster enrollment.
Who is not eligible for the QuickStart program?
The patients with Medicare, Medicaid, DoD, Tricare, VA, and other insurance plans are not eligible for the QuickStart program.
What happens after I submit my Vumerity Biogen start form?
A Biogen support coordinator and specialty pharmacy will contact you to discuss treatment support and arrange medication delivery.
What documents should I attach to the form?
Attach copies of the front and back of all medical insurance, prescription, and pharmacy benefit cards. Additionally, if you have a secondary insurance, attach those details as well.
What is the Vumerity patient assistance program?
It is a part of Biogen Support Services and is designed to help eligible commercially insured patients manage the cost of treatment. The Vumerity patient assistance program includes co-pay assistance, the QuickStart Program, and other financial assistance programs.
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