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

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Print out and complete the HAEGARDA Prescription Referral form.


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Starting your patient on HAEGARDA with the QuickStart program? Print out and complete both the HAEGARDA Prescription Referral form AND the QuickStart Program* Form.

Step 2

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

Step 3

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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.

Additional forms

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Statement of Medical Necessity

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Appeal/Denial Sample Letter

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Formulary Exception Sample Letter

If you need to file an appeal, whether standard or urgent, contact HAEGARDA Connect at 1-844-HAEGARDA (1-844-423-4273) to be connected with one of CSL Behring’s Field Reimbursement Managers.

HAEGARDA Connect will confirm receipt and may contact you for additional documents requested by insurer

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