The Aubagio One to One Start Form is designed to facilitate access to Aubagio® (teriflunomide) treatment for patients with relapsing forms of multiple sclerosis (MS). This form helps patients enroll in the One to One Support Services, which provide personalized assistance, including insurance benefit verification, educational resources, and access to a dedicated nurse.
Purpose of the Aubagio One to One Start Form
The Aubagio One to One Start Form is designed to facilitate patient access to Aubagio® support services by:
- Verifying Insurance Benefits: Helps confirm insurance coverage and eligibility for financial assistance.
- Setting Up Prescriptions: Coordinates with specialty pharmacies to ensure medication delivery.
- Providing Educational Resources: Offers tailored information and support for patients and caregivers.
- Connecting with a One to One Nurse: Provides personalized support, answering questions and addressing concerns.
Steps for Prescribers
To complete the ‘Aubagio One to One Start Form,’ prescribers must follow these steps:
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Patient Review:
- Have the patient read the description of One to One Support Services on page 2.
- Have the patient read the Authorizations on pages 2 and 3.
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Patient Authorization:
- Ensure the patient signs sections I(a) and I(b) on page 4 if they wish to grant authorization.
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Form Completion:
- Complete the rest of the Start Form.
- Sign the Prescriber Authorization.
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Documentation:
- If available, copy both sides of the patient’s insurance card and pharmacy benefit card.
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Submission:
- Fax page 4 of the Start Form along with copies of the insurance cards to 1-855-557-2478.
These steps ensure the patient can access the One to One Support Services for Aubagio.
Patient Instructions
Instructions for Patients
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Read the Overview:
- Review the description of One to One Support Services on page 2.
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Authorization:
- Read the One to One Services Authorization on page 2.
- Read the Authorization to Share Health Information on page 3.
- Sign sections I(a) and I(b) on page 4 if you agree.
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Provide Information:
- Give your doctor your insurance card and pharmacy benefit card.
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Doctor’s Role:
- Your doctor will complete the rest of the form and fax it.
After Submission
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Verification:
- Your insurance benefits will be verified within a few business days.
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Contact:
- Expect a call from a One to One Nurse within 2-3 business days. This might come from an unfamiliar number.
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Support:
- You will receive support regarding your medication, insurance, and educational resources.
If you have any questions, you can call 1-855-676-6326 or visit AUBAGIO.com.
Benefits of the Aubagio One to One Start Form
Using the Aubagio One to One Start Form offers several benefits for patients:
- Insurance Verification: Helps verify insurance benefits.
- Cost Savings: Eligible patients may receive therapy at no cost for up to one year during benefit verification.
- Educational Resources: Access to educational materials for patients and care partners.
- Personalized Support: A dedicated One to One Nurse to answer questions, discuss lifestyle concerns, and provide tailored information.
These services aim to make the treatment process smoother and more supportive for patients.
The Aubagio One to One Start Form
The Aubagio One to One Start Form is crucial for patients with relapsing forms of multiple sclerosis (MS) as it facilitates access to personalized assistance, insurance benefit verification, educational resources, and dedicated nurse support.
By completing this form, patients can ensure a smooth start to AUBAGIO treatment and ongoing support, including cost savings, insurance verification, educational resources, and personalized support from a dedicated One to One Nurse.
