Injectafer Insurance Verification Form
50 kg give injectafer in 2 doses of 750 mg doses separated by at least 7 days 750 mg ml vials qty refills.
Injectafer insurance verification form. Check with your pharmacist or healthcare provider for your copay discount. Injectafer is contraindicated in patients with hypersensitivity to injectafer or any of its inactive components. Prescribing of injectafer by signing page 1 of this form i certify that a copy of the patient. Iv iron reimbursement hotline will contact the insurance company or companies listed below to determine coverage for injectafer as requested.
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. 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. Injectafer is injected into your vein to treat iron deficiency anemia in adults.
For the treatment of iron deficiency anemia ida in adult patients who have intolerance to oral iron have had unsatisfactory response to oral iron or have non dialysis dependent chronic kidney disease injectafer is the only iv iron treatment that provides up to 1500 mg of iron per course in 2 administrations of 750 mg separated by at least 7 days. 100 passaic ave suite 245 fairfield nj 07004. This form is used by the office in the event there is an issue with the processing of the injectafer savings program financial card. Insurance verification request form please complete all sections and fax to.
The injectafer savings program. 888 354 4856 patient information do you have the patient s consent on file. Warnings and precautions symptomatic hypophosphatemia requiring clinical intervention has been reported in patients at risk of low serum phosphate in the postmarketing setting. Injectafer is a prescription iron replacement medicine administered only by or under the supervision of your healthcare provider.
Check with your pharmacist or healthcare provider for your copay discount. 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 per course of therapy.
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