File name: Ajovy Patient Assistance Form Pdf

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👉Ajovy Patient Assistance Form Pdf

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Information on prescribing AJOVY, prior authorization, and formulary coverage. Get your patients started on AJOVY today. For NEW Patient Copay Assistance information, please click on this linkMissing: Pdf. /5 (K reviews)A tool that fits easily into your workflow – CIOReview. Learn about the financial assistance programs for Ajovy, a CGRP inhibitor for migraine prevention, from Teva and other sources. Find out how to get a Savings Card, a Patient .  Pr ® TO ENROL YOUR PATIENTS IN THE AJOVY® TEVA SUPPORT SOLUTIONS® (AJOVY TSS) PATIENT SUPPORT PROGRAM, PLEASE COMPLETE THIS FORM AND RETURN IT TO: Fax: Email: TSS@ PATIENT INFORMATION Last name: First name: Gender: M F Other Date of birth: YYYY | MM | DD Patient health card: Address: City: Province. the form to the AJOVY TSS program. The AJOVY TSS enrolment form will need to be signed and dated with your consent. Note: even if the prescriber makes a reimbursement submission on your behalf directly to a payer, they are encouraged to enrol you in the AJOVY TSS program in parallel to allow you to benefit from the services available to you. 4. Patient Assistance Program. For patients who are uninsured or unable to afford AJOVY, the Teva Cares Foundation may be able to help. Teva Cares is an independent, non-profit organization that provides AJOVY at no cost to eligible patients. † To learn more visit or call