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This document is a fax-back sheet for prescribers to provide necessary information regarding patients eligible for Incretin Mimetics. It includes coverage criteria and allows for patient information
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How to fill out incretin mimetics step fax-back
How to fill out Incretin Mimetics Step Fax-back Sheet
01
Begin by entering the patient's personal information at the top of the sheet including name, date of birth, and insurance details.
02
Fill in the prescribing physician's information, including contact details.
03
Indicate the specific Incretin Mimetics medication being requested.
04
Provide the patient's medical history relevant to the condition being treated with Incretin Mimetics.
05
Document any previous treatments the patient has undergone, including outcomes and reasons for discontinuation.
06
Include current medications that the patient is taking to ensure there are no contraindications.
07
Attach any required lab results or weight measurements that support the need for Incretin Mimetics.
08
Review all information for accuracy and completeness before submission.
09
Sign and date the form to confirm all information is true and accurate.
Who needs Incretin Mimetics Step Fax-back Sheet?
01
Patients who are prescribed Incretin Mimetics for the management of type 2 diabetes may need this Step Fax-back Sheet.
02
Healthcare providers who seek prior authorization to ensure coverage for the use of Incretin Mimetics need to complete this form.
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What is included in incretin mimetics?
FORMS Brand NamePreparationStrength Bydureon exenatide 2 mg per pen Victoza/Saxenda liraglutide 18 mg/3 mL Symlin pramlintide 1500 mcg/1.5 mL or 2700 mcg/2.7 mL Trulicity dulaglutide 0.75 mg/0.5 mL; 1.5 mg/0.5 mL; 3 mg/0.5 mL; 4.5 mg/0.5 mL5 more rows
How much does Afrezza cost per month?
$35 price cap It already limits the cost to $35 for all uninsured patients. Novo Nordisk in September launched the MyInsulinRx program, which provides a 30-day supply of insulin for $35 to eligible patients, including the uninsured.
How much does GLP-1 cost per month?
If the patient's health plan does not cover Afrezza® or requires a prior authorization, contact AfrezzaAssist℠ for more information. If approved by the patient's health plan to take Afrezza®, a patient will pay as little as $35 per month.
How much do incretin mimetics cost?
Drugs in the incretin mimetic class include exenatide (Byetta, Bydureon), liraglutide (Victoza), sitagliptin (Januvia, Janumet, Janumet XR, Juvisync), saxagliptin (Onglyza, Kombiglyze XR), alogliptin (Nesina, Kazano, Oseni), and linagliptin (Tradjenta, Jentadueto).
Is Ozempic an incretin mimetic?
Exenatide is a member of the GLP-1 Agonists (Incretin Mimetics) drug class and is commonly used for Type 2 Diabetes. Brand names for exenatide include Byetta. The cost for exenatide (10 mcg/0.04 mL) subcutaneous solution is around $688 for a supply of 2.4 milliliters, depending on the pharmacy you visit.
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What is Incretin Mimetics Step Fax-back Sheet?
The Incretin Mimetics Step Fax-back Sheet is a form used by healthcare providers to request prior authorization for incretin mimetics medications, which are used to manage type 2 diabetes.
Who is required to file Incretin Mimetics Step Fax-back Sheet?
Healthcare providers, such as physicians and their administrative staff, are required to file the Incretin Mimetics Step Fax-back Sheet when seeking prior authorization for their patients.
How to fill out Incretin Mimetics Step Fax-back Sheet?
To fill out the Incretin Mimetics Step Fax-back Sheet, providers should complete patient identification information, specify the requested medication, provide clinical information supporting the use of incretin mimetics, and include any previous treatment history.
What is the purpose of Incretin Mimetics Step Fax-back Sheet?
The purpose of the Incretin Mimetics Step Fax-back Sheet is to streamline the prior authorization process, ensuring that patients meet the required criteria for coverage of incretin mimetics medications.
What information must be reported on Incretin Mimetics Step Fax-back Sheet?
The information that must be reported on the Incretin Mimetics Step Fax-back Sheet includes patient demographics, medication details, medical history relevant to diabetes management, treatment outcomes from previous medications, and supporting clinical evidence.
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