CVS Caremark Tysabri Enrollment Form
This file is the enrollment form for Tysabri (natalizumab) through CVS Caremark. It includes patient and prescriber information, insurance details, medical necessity statement, and prescription information. Follow the outlined steps for each section to complete the form.
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How do I fill this out?
Follow these steps to complete the Tysabri Enrollment Form accurately. Ensure you provide all the necessary details as requested in each section. Missing information may affect the outcome of your request.
How to fill out the CVS Caremark Tysabri Enrollment Form?
1
Fill in patient information including name, contact details, and date of birth.
2
Complete prescriber information section with relevant medical IDs and contact details.
3
Provide insurance information and fax copies of medical and pharmacy cards.
4
Check all applicable boxes in the statement of medical necessity section.
5
Fill out the prescription information with medication details and refill instructions.
Who needs the CVS Caremark Tysabri Enrollment Form?
1
Patients prescribed Tysabri for Multiple Sclerosis need this form to enroll in the program.
2
Prescribers who are registering a patient for Tysabri treatment through CVS Caremark.
3
Healthcare providers documenting medical necessity for insurance purposes.
4
Insurers verifying patient eligibility and prescription details for Tysabri.
5
Pharmacists processing Tysabri prescriptions and refills based on this form.
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What are the instructions for submitting this form?
To submit the Tysabri Enrollment Form, fax it to 800-323-2445 or call 800-237-2767 for more information. Make sure all sections of the form are filled out completely and legibly. Include copies of medical and pharmacy cards and ensure all approval criteria are met. Submit the original form to the address provided or scan and email it as directed by CVS Caremark.
What is the purpose of this form?
The primary purpose of the Tysabri Enrollment Form is to ensure proper documentation of patient and prescriber information for those prescribed Tysabri. This form helps in verifying the medical necessity of the treatment and facilitates insurance approval processes. Additionally, it assists pharmacists in processing and dispensing Tysabri prescriptions accurately.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Includes patient name, contact details, date of birth, and social security number.
- 2. Prescriber Information: Requires prescriber's name, contact information, medical IDs, and the name of the hospital or group.
- 3. Insurance Information: Needs copies of medical and pharmacy insurance cards and additional insurance details.
- 4. Medical Necessity: Checklist for diagnosis, treatment history, and approval criteria for Tysabri usage.
- 5. Prescription Information: Details the medication, strength, directions for use, quantity, and refill instructions.
- 6. Important Notice: Alerts the recipient about the confidentiality and proper handling of the form.
What happens if I fail to submit this form?
Failure to submit the Tysabri Enrollment Form may result in delayed or denied treatment.
- Treatment Delay: Incomplete enrollment can postpone the initiation of Tysabri therapy.
- Insurance Approval: Missing information may lead to an inability to obtain insurance coverage.
- Pharmacy Processing: Pharmacists require a complete form to dispense the medication.
- Patient Care: Timely treatment is essential for patients with MS or Crohn's disease.
How do I know when to use this form?
- 1. Initial Enrollment: To officially enroll a patient in the Tysabri program.
- 2. Insurance Verification: For insurers to verify patient eligibility and coverage for Tysabri.
- 3. Prescription Processing: Pharmacists use it to dispense Tysabri as prescribed.
- 4. Medical Documentation: Healthcare providers document the necessity for Tysabri treatment.
- 5. Clinical Trials: Patients participating in related clinical trials may need this form.
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What information do I need to fill out the Tysabri Enrollment Form?
You need patient and prescriber information, insurance details, medical necessity statements, and prescription instructions.
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