Injectafer Insurance Verification Form
The injectafer savings program.
Injectafer insurance verification form. If you have a patient enrolled in the injectafer patient assistance program and are in need of product replacement for your practice please fill out the product request form and fax it to 1 888 354 4856 after the patient s infusion. Iv iron reimbursement hotline will contact the insurance company or companies listed below to determine coverage for injectafer as requested. Check with your pharmacist or healthcare provider for your copay discount. Check request form all documentation can also be mailed to.
Injectafer is injected into your vein to treat iron deficiency anemia in adults. Injectafer ferric carboxymaltose injection 750 mg 15 ml 50 kg 15 mg kg give injectafer in 2 doses separated by at least 7 days and each dose as 15 mg kg body weight 750 mg ml vials qty. 888 354 4856 patient information do you have the patient s consent on file. Depending on insurance coverage eligible insured patients may pay no more than 50 for injectafer for the first dose and 0 for injectafer for the second dose up to a maximum savings limit of 500 per dose a 1 000 program limit for coverage up to two doses.
Warnings and precautions symptomatic hypophosphatemia requiring clinical intervention has been reported in patients at risk of low serum phosphate in the postmarketing setting. This form is used by the office in the event there is an issue with the processing of the injectafer savings program financial card. Injectafer is contraindicated in patients with hypersensitivity to injectafer or any of its inactive components. 100 passaic ave suite 245 fairfield nj 07004.
Prescribing of injectafer by signing page 1 of this form i certify that a copy of the patient. Check with your pharmacist or healthcare provider for your copay discount. 50 kg give injectafer in 2 doses of 750 mg doses separated by at least 7 days 750 mg ml vials qty refills. Injectafer should be used only if you have not responded well to treatment with oral iron or if you are intolerant to oral iron treatment.
Verify investigate and help coordinate my coverage for injectafer with my health insurance company assist with analyses of the efficiencies and performance of the. Insurance verification request form please complete all sections and fax to.
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