The Provider Portal allows registered users to complete the enrollment form online
BESPONSA® (inotuzumab ozogamicin) & MYLOTARG™ (gemtuzumab ozogamicin) Specialty Distributors
Letter Of Medical Necessity Checklist
Sample Letter Of Medical Necessity
Prior Authorization Checklist
Sample Letter Of Appeals
Sample Letter For Requesting FORMULARY Exception
*The information contained in these template letters is provided by Pfizer for informational purposes for patients prescribed a Pfizer medicine. These templates are not intended to substitute for a prescriber’s independent medical decision-making.
NIVESTYM® (filgrastim-aafi) BILLING & CODING GUIDE
NYVEPRIA™ (pegfilgrastim-apgf) Billing & Coding Guide
RETACRIT® (epoetin alfa-epbx) Billing & Coding Guide
RUXIENCE® (rituximab-pvvr) Billing & Coding Guide
TRAZIMERA® (trastuzumab-qyyp) Billing & Coding Guide
ZIRABEV® (bevacizumab-bvzr) Billing & Coding Guide
View Q codes for BIOSIMILAR medications
BESPONSA Sample UB-04/CMS-1450 Form For Hospital Outpatient Use
BESPONSA Sample CMS-1500 Form For Physician Office Use
MYLOTARG Sample UB-04/CMS-1450 FORM FOR HOSPITAL OUTPATIENT USE
MYLOTARG Sample CMS-1500 Form For Physician Office Use
†The information provided here is intended for informational purposes only and is not a comprehensive description of potential coding requirements for BESPONSA, MYLOTARG, ZIRABEV, RUXIENCE, TRAZIMERA, RETACRIT, and NIVESTYM. Coding and coverage policies change periodically and often without warning. The healthcare provider is solely responsible for determining coverage and reimbursement parameters and accurate and appropriate coding for treatment of his/her own patients. The information provided in this section should not be considered a guarantee of coverage or reimbursement for BESPONSA, MYLOTARG, ZIRABEV, RUXIENCE, TRAZIMERA, RETACRIT, and NIVESTYM.
The sample forms are intended as a reference for billing and coding of BESPONSA, MYLOTARG, ZIRABEV, RUXIENCE, TRAZIMERA, RETACRIT, and NIVESTYM. These forms are not intended to be directive or to replace clinical decision-making, and the use of the recommended codes does not guarantee reimbursement. Healthcare providers may deem other codes or policies more appropriate and should select the coding options that most accurately reflect their internal guidelines, payer requirements, practice patients, and the services rendered.
Co-Pay Savings Program Claim Form (Injectables)
Overview for Enrollment and Claim Submission (INJECTABLES)
CO-PAY SAVINGS Program for Oral Products Brochure (For Patients)
CO-PAY SAVINGS PROGRAM FOR Injectable PRODUCTS BROCHURE (FOR PATIENTS)
AROMASIN® (exemestane) SAVINGS CARD TIP SHEET
NIVESTYM Co-Pay Savings Program Brochure
NYVEPRIA Co-Pay Savings Program Brochure
RUXIENCE CO-PAY SAVINGS PROGRAM BROCHURE
TRAZIMERA CO-PAY SAVINGS PROGRAM BROCHURE
ZIRABEV CO-PAY SAVINGS PROGRAM BROCHURE
Download sample resources from the Care Champion Program for your practice.