HAEGARDA PRESCRIPTION FORM

To get your patients started on HAEGARDA, complete this Prescription Form and fax it to 1-866-415-2162. By completing this form, you’ll be providing your patients with the efficacy of HAEGARDA and all the additional benefits that go along with their prescriptions, including nurse visits for training and coverage support.

Call HAEGARDA ConnectSM at 1-844-HAEGARDA (1-844-423-4273) 8 AM to 8 PM ET.

PRIOR AUTHORIZATION CHECKLIST

This printable prior authorization and re-authorization checklist and common requirements document was created based on top payer policies but should not be considered specific to one particular plan.

STATEMENT OF MEDICAL NECESSITY

The HAE Medical Necessity Form includes common information that may be required by the payer to authorize coverage for HAEGARDA®. Please refer to the payer plan for specific authorization requirements.



REIMBURSEMENT AND CODING GUIDE

Access ICD-10-CM diagnosis, HCPCS, CPT®, and NDC billing codes for HAEGARDA.



ADDITIONAL FORMS




*NOTE FOR THE OFFICE: You can file an expedited appeal if the timeline for the standard appeal process affects the patient. A final decision about your expedited appeal must come as quickly as the medical condition requires, and at least within 4 business days after the request is received.

You are now leaving the current website.