START SMART WITH HAEGARDA
To help get patients started on HAEGARDA faster:
Print and fill out the forms below prior to your patient’s visit in case additional information from their insurance company is requested.
Print out and complete the HAEGARDA Prescription Referral form.
Starting your patient on HAEGARDA with the QuickStart program? Print out and complete both the HAEGARDA Prescription Referral form AND the QuickStart Program* Form
Use the Prior Authorization Checklist to verify you have diagnostics insurers often require.
Fax completed HAEGARDA Prescription Referral Form to HAEGARDA ConnectSM at 1-866-415-2162.
* Eligible patients can continue the program and receive up to 3 months of HAEGARDA at no cost. Continued supply of HAEGARDA may be extended during the commercial insurance approval process.
Statement of Medical Necessity
Appeal/Denial Sample Letter*
Formulary Exception Sample Letter
* If you need to file an appeal, whether standard or urgent, contact HAEGARDA ConnectSM at 1-844-HAEGARDA (1-844-423-4273) to be connected with one of CSL Behring’s Field Reimbursement Managers.
HAEGARDA ConnectSM will confirm receipt and may contact you for additional documents requested by insurer.