Resources

HEALTHCARE PROFESSIONAL RESOURCES
ACCESSING ROLVEDON^®

• ACCESS4Me Overview Brochure

  Includes guidance on completing the Enrollment Form and understanding the results of the Benefits Summary

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• Patient Support and Copay Assistance Guide for Healthcare Professionals

  A brochure for healthcare professionals that explains the patient support available for eligible patients through ACCESS4Me

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• First-Cycle Patient Support Flashcard (Hospital Outpatient Settings Only)

  Useful information on the First-Cycle Patient Support—how it works and how to request product

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• Provider Portal User's Guide

  Detailed guide covering registration, set up, the enrollment process, and portal functionality

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• ACCESS4Me Enrollment Form

  Use this form to get started and enroll your patients in ACCESS4Me. We will verify insurance coverage and determine program eligibility based on the support requested. Online enrollment is also available on the ACCESS4Me Provider Portal

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• Product Fact Sheet

  Includes pertinent information on ROLVEDON

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• Product Replacement Form

  Use this form to request replacement product for patient support programs and the Claims Denial Program

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• Bridge Program (Office Settings Only)

  Useful information on the Bridge Program - how it works and how to request product

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• Prior Authorization Checklist

  A checklist to guide you through the prior authorization process

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REIMBURSEMENT

• Reimbursement Guide

  Includes suggested billing codes for ROLVEDON, information on payment methodology, and sample CMS 1450 and 1500 forms

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• Coding Reference Flashcard

  Convenient flashcard to reference when billing for ROLVEDON

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• ROLVEDON J-code Announcement

  Permanent J-code information for ROLVEDON

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LETTERS AND DOCUMENTS

• Sample Letter of Medical Necessity

  An example of the information that may be provided when responding to a request from a patient’s health plan to provide a letter of medical necessity for ROLVEDON treatment

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• Sample Appeal Letter for Prior Authorization Denial

  An example of the information that may be provided when appealing a denial from a patient’s health plan for ROLVEDON treatment

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• Sample Appeal Letter for Claim Denial

  An example of the information that may be provided when appealing a denial from a patient’s health plan for ROLVEDON treatment

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• FDA Approval Letter

  Letter from the FDA approving ROLVEDON in the United States

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• ROLVEDON Prescribing Information

  Complete prescribing information for ROLVEDON including approved indication, efficacy, and safety

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PATIENT RESOURCES

• Patient Support and Copay Assistance Guide for Patients

  A brochure for patients that explains the support services available through ACCESS4Me

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• First-Cycle Patient Support Terms and Conditions (Hospital Outpatient Settings Only)

  Complete terms and conditions for the First-Cycle Patient Support Program and how to request replacement product

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• Patient Authorization and Certification Form

  Patient HIPAA authorization and support program certification. Patient signatures may also be captured on the ACCESS4Me enrollment form

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• Patient and Caregiver Guide

  A comprehensive, patient-friendly guide containing information about the diagnosis, treatment, side effects, and at-home injection instructions for ROLVEDON.

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• Bridge Program Terms and Conditions (Office Settings Only)

  Complete terms and conditions for the Bridge Program and how to request a replacement product.

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