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.

Step 1

pen and text icon

Print out and complete the HAEGARDA Prescription Referral form.

Step 2

pen and text icon

Use the Prior Authorization Checklist to verify you have diagnostics insurers often require.

Step 3

print icon

Fax completed HAEGARDA Prescription Referral Form to HAEGARDA ConnectSM at 1-866-415-2162.

Additional forms

pdf icon

Statement of Medical Necessity

pdf icon

Appeal/Denial Sample Letter*

pdf icon

Formulary Exception Sample Letter

* If you need to file an appeal, whether standard or urgent, contact HAEGARDA ConnectSM at 1-888-HAEGARDA (1-888-423-4273) 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.

Find more resources here

RESOURCES
You are now leaving the current website.

Do you want to continue?