AbbVie Patient Access Support: SKYRIZI® (risankizumab-rzaa) Applications and Instructions
This file contains important information and instructions about AbbVie's Patient Access Support programs for SKYRIZI® (risankizumab-rzaa). It provides guidelines on how to apply for financial assistance and details the terms of participation. Essential for patients and prescribers.
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How do I fill this out?
To fill out this form, follow these preliminary steps. Ensure you have read all terms of participation, privacy notice, and financial information. Have your health insurance details and prescriber's information ready.
How to fill out the AbbVie Patient Access Support: SKYRIZI® (risankizumab-rzaa) Applications and Instructions?
1
Carefully read the terms of participation, privacy notice, financial information, and HIPAA authorizations on pages 1-3.
2
Complete the enrollment & prescription form on page 5.
3
Provide your consent for eligibility determination and confirm your understanding of the Terms of Participation by providing your signature and date.
4
Include front and back copies of all insurance cards if you have health insurance.
5
Submit the form and required documentation via fax, mail, or online.
Who needs the AbbVie Patient Access Support: SKYRIZI® (risankizumab-rzaa) Applications and Instructions?
1
Patients prescribed SKYRIZI® who need financial assistance.
2
Prescribers enrolling patients into AbbVie's assistance programs.
3
Patients with Medicare Part D seeking additional support.
4
Individuals recently denied coverage but needing medication.
5
Patients with insurance requiring additional verification.
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What are the instructions for submitting this form?
To submit this form: FAX to 1-866-250-2803, or mail to AbbVie Patient Access Support, D-617927, AP5 NE, 1 N. Waukegan Rd., North Chicago, IL 60064. You can also complete it online at www.AbbVie.com/PAS. Ensure all sections are filled and required documents included. Verify all provided information before submission.
What are the important dates for this form in 2024 and 2025?
Relevant dates: By June 2024, ensure all personal, insurance, and financial data is correctly submitted. The form and support services are relevant through the end of 2025, keep copies for your records.
What is the purpose of this form?
The purpose of this form is to facilitate access to AbbVie's Patient Access Support programs for the medication SKYRIZI® (risankizumab-rzaa). Through this form, patients can apply for financial assistance and understand the terms of their participation. It ensures that all required data, including insurance information and consents, are collected for a thorough eligibility determination process, providing much-needed support without financial barriers.
Tell me about this form and its components and fields line-by-line.
- 1. Terms of Participation: Outlines the conditions and terms for participating in the program.
- 2. Privacy Notice: Details how personal data will be collected, used, and protected.
- 3. HIPAA Authorization: Consents to the use and disclosure of the patient's protected health information.
- 4. Enrollment Form: Requires patients to provide detailed information including insurance and financial data.
- 5. Prescriber's Section: To be filled out by the prescriber with prescription details and confirmation of accuracy.
- 6. Submission Instructions: Provides guidelines on how and where to submit the completed form.
What happens if I fail to submit this form?
Failing to submit the form may result in ineligibility for the AbbVie Patient Access Support programs.
- Ineligibility for Financial Assistance: You may not receive the financial support needed for your medication.
- Interruption of Medication Access: Problems submitting forms can lead to delays or halts in medication access.
How do I know when to use this form?
- 1. Enrollment: For initial enrollment in the financial assistance program.
- 2. Re-Enrollment: To renew participation when the term expires.
- 3. Updating Information: If there are any changes in your insurance or financial information.
- 4. Appealing Denials: When facing a denial and you need support with re-evaluation.
- 5. Adding Prescriptions: To add new or additional prescription under the program.
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