Veloxis has created the Veloxis Transplant Support program to assist patients in obtaining access to Veloxis medications. Applications are reviewed and eligibility is verified. Determinations are made on a case-by-case basis using pre-determined eligibility requirements regarding coverage and financial criteria.
After the Form has been submitted, including Financial Documentation and Insurance Cards, your Veloxis Transplant Support (VTS) Specialist will review the application and then notify both provider and patient of next steps.
Patients enrolled in patient assistance are approved for a maximum of 12 months of eligibility at a time and must reapply to re-validate their eligibility annually. VTS will contact you to re-validate your eligibility for Patient Assistance before the current eligibility period expires.
Note for Medicare Part D Participants: When interfacing with a Medicare Part D beneﬁciary, the Veloxis PAP will operate outside of the Medicare Part D beneﬁt. Any assistance provided to a patient for drugs that would have been covered under their Part D plan will not count as an incurred cost that would be applied toward the enrollee’s TrOOP balance or total drug spend.
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(Please upload copies of both sides of patient applicant's insurance cards)
Only the prescriber is allowed to sign
This form does not constitute a valid prescription. If your patient is approved, the filling specialty pharmacy will reach out to you to obtain a valid prescription.
Note: This section is required for patients requesting to enroll in the Patient Assistance Program in order to verify eligibility.
Please provide proof of household income. Include one or more of the following documents to provide proof of all income numbers reported above.
PATIENT AUTHORIZATION FOR ELECTRONIC INCOME VERIFICATION
PATIENT AUTHORIZATION FOR PHI DISCLOSURE
Patient attestation of no insurance coverage (if applicable)
Draw your signature into the box to the left
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