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PRESCRIBING INFORMATION


CONTACT US

Phone: 1-855-6XOFIGO

            (1-855-696-3446)

Fax:    1-855-963-4463


Monday through Friday
9:00 A.M. to 8:00 P.M ET
Contact Address:
Xofigo Access Services
PO Box 220009
Charlotte, NC 28222-0009

   
   

Xofigo Access Services


Program Forms and Resources

The list below are our most common forms for patient needs

Xofigo® Quick Start Guide
Xofigo® Patient Authorization Form

Submit this form with any initial patient request. The patient's signature on this form authorizes the use and/or disclosure of PHI. This form is required to complete the Patient Assistance Program and Commercial Copay Assistance applications.


Xofigo® Access Services Brochure
This brochure is designed to give you an overview of Xofigo Access Services, your single point of contact for assistance with product ordering, confirming patient scheduling and shipments reimbursement support, and patient assistance.

Xofigo® Access Services Benefit Verification Form for Referring Providers

Use this form to request insurance coverage benefits verification for your patients through Xofigo Access Services


Xofigo® Access Services Intake Form for Administering Providers

Use this form to request benefit verification, set a treatment schedule, or place an order


Xofigo® Access Services Intake Form for VA/DoD
Use this form to set a treatment schedule or place an order

Xofigo® Access Services Application for Patient Assistance/Commercial Copay Assistance

Use this form to apply for patient assistance of commercial copay assistance for your patients on Xofigo


Quick Reference Reimbursement Guide for Freestanding Centers

This guide is designed to provide you with coding and reimbursement information to support healthcare professionals and office staff in prescribing Xofigo.


Quick Reference Reimbursement Guide for Hospital Outpatient Departments

This guide is designed to provide you with coding and reimbursement information to support healthcare professionals and office staff in prescribing Xofigo.


Xofigo® Access Support for Patients Brochure

This brochure is designed to provide your patients with information about patient access programs available for patients taking Xofigo including the patient assistance program, commercial copay assistance program and copay assistance program for uninsured patients.


Get Started With Xofigo® Guide for Referring Providers

This guide is intended to give you an overview of Xofigo Access Services can help patients get started with Xofigo.


Ordering Xofigo Guide for Administering Providers

This guide is intended to give you an overview of the 3 step process to get your patient started in Xofigo.


Sample letter of Medical Necessity

This sample letter is intended to provide physicians with language that can be used in their correspondence with insurance companies to justify coverage for Xofigo for their patients.


Sample letter of Appeal

This sample letter is intended to provide physicians with language that can be used in their correspondence with insurance companies to respond to queries regarding coverage for Xofigo for their patients.

©2015 Bayer HealthCare Pharmaceuticals Inc. Bayer, the Bayer Cross,  Xofigo and the Xofigo Access Services logo are registered trademarks of Bayer.

Site Last Modified: 03/2015            Terms of Use | Privacy | Site Map