Access 360 General Patient Authorization Form (PAF)

Find the right resources to assist your FASENRA patients

FASENRA Overview of Key Steps Updated

FASENRA Overview of Key Steps

A single-page overview of the key steps for obtaining FASENRA.

FASENRA Enrollment Form and Patient Authorization

FASENRA Enrollment Form

A multi-page enrollment form to capture necessary patient, provider, and prescription information to start a new request for support.

FASENRA Saving Program Affordability Information

FASENRA Savings Program Affordability Information

A two-page resource describing ways in which patients can pay for FASENRA if it is approved or denied.

FASENRA C-Code Coding Resource

FASENRA Coding Resource

This resource provides specific codes related to diagnosing and billing for FASENRA. FASENRA J-Code: J0517

FASENRA J-Code Flashcard

FASENRA J-Code Flashcard

Use this resource to ensure the correct code is used to identify FASENRA.

FASENRA Access and Reimbursement Guide C-Code Update

FASENRA Access and Reimbursement Guide

This guide contains general information on dosing, distribution, support services, and reimbursement for FASENRA.

FASENRA Acquisition Distribution Card

FASENRA Distribution Sheet

This sheet provides the contact information of authorized Specialty Pharmacy Providers and Specialty Distributors, from which FASENRA can be obtained.

FASENRA Prior Authorization and Appeal Checklist

FASENRA Prior Authorization and Appeal Checklist

Checklists designed to be used as a reference during the prior authorization (PA) and denial/appeal processes for FASENRA.

FASENRA Sample Letter of Medical Necessity

FASENRA Sample Letter of Medical Necessity

This template is offered as a resource a healthcare provider could use when responding to a request from a patient’s insurance company to provide a letter of medical necessity for prescribing FASENRA.

FASENRA Access 360 Sample Letter of Appeal

FASENRA Sample Appeal Letter

This template is a sample resource a healthcare provider could use when responding to a request from a patient's insurance company to provide a letter of medical necessity for prescribing FASENRA.

FASENRA Low EOS Count

FASENRA Sample Letter of Appeal – Low Count

This template can be used by a healthcare provider to appeal a denial of access to FASENRA.

FASENRA Product Change

FASENRA Sample Letter of Appeal – Product Change

This template can be used by a healthcare provider to appeal a denial of access to FASENRA.

FASENRA Sample Plan Exception Request Letter

FASENRA Sample Plan Exception Request Letter

This template is a sample resource a healthcare provider could use when responding to a request from a patient's insurance company to provide a letter of medical necessity for prescribing FASENRA.

FASENRA Denied Patient Savings Program Form

FASENRA Denied Co-pay Savings Program Form

A single-page form for patients who have been denied FASENRA.

FASENRA Technology Resources Card

FASENRA Technology Information

An overview of technology resources for managing your FASENRA patients.

FASENRA Patient Injection Record

FASENRA Patient Injection Record

A log for you to keep track of injections administered to your FASENRA patients.