Enrollment - YUVIWEL® (navepegritide) HCP Website

Patient support services requested:

YUVIWEL FastStart Injection training support Ascendis Patient Assistance Program A·S·A·P Bridge Support

Patient First Name*:

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Patient Last Name*:

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Date of Birth*:

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Sex*:

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Address*:

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City*:

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State*:

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Zip Code*:

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Primary Language:

Parent/Guardian #1 First Name*:

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Parent/Guardian #1 Last Name*:

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Relationship to Patient*:

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Parent/Guardian #1 Phone Number*:

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Parent/Guardian #1 Email:

Please enter a valid email address.

Parent/Guardian #2 First Name:

Parent/Guardian #2 Last Name:

Relationship to Patient:

Parent/Guardian #2 Phone Number:

Parent/Guardian #2 Email:

Please enter a valid email address.

Please select the appropriate statement:*

Patient has pharmacy insurance Patient is not insured

Primary Medical Insurance*:

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Pharmacy/Rx Insurance:

Member ID #*:

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Group ID #:

Member First Name:

Member Last Name:

Phone Number:

Patient Insurance Card (Front):

Patient Insurance Card (back):

Prior Authorization (PA) Submitted:

Yes No

PA Approval:

Yes No

Date of PA approval:

Reference Number:

Please check box to confirm ICD-10 diagnosis: Q77.4 Achondroplasia*
ICD-10 CM Q77.4 is used for achondroplasia; YUVIWEL is only indicated for increasing linear growth in pediatric patients with achondroplasia and open growth plates (epiphyses).

Please provide the following details:

Current Weight*

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Date of measure*:

Current Height

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Date of measure:

Known drug allergies:

Yes No

If yes, list allergies:

Concurrent medications:

Confirmed FGFR3 mutation

Date of test:

Open epiphyses*:

Yes No

X-ray date:

FGFR3= fibroblast growth factor receptor-3; SC= subcutaneous

Prescriber First Name*

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Prescriber Last Name*

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Practice Name*:

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DEA #:

Prescriber NPI #*

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Address*:

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City*:

State*:

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Zip Code*:

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Office Contact First Name*:

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Office Contact Last Name*:

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Office Contact Phone*:

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Office Contact Fax*:

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Office Contact Email*:

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YUVIWEL weekly subcutaneous dose and injection volume (please select the weekly dose/injection volume based on the patient's body weight)*:

1.3 mg vial (NDC 73362-201-01)

8.0 to 9.9 kg; 0.88 mg (0.40 mL) SC weekly 10.0 to 13.4 kg; 1.2 mg (0.55 mL) SC weekly

2.8 mg vial (NDC 73362-202-01)

13.5 to 17.5 kg; 1.6 mg (0.35 mL) SC weekly 17.6 to 23.0 kg; 2.1 mg (0.45 mL) SC weekly 23.1 to 30.5 kg; 2.8 mg (0.60 mL) SC weekly

5.5 mg vial (NDC 73362-203-01)

30.6 to 41.2 kg; 3.6 mg (0.65 mL) SC weekly 41.3 to 55.9 kg; 5.0 mg (0.90 mL) SC weekly 56.0 to 73.5 kg; 6.6 mg (2 x 0.60 mL) SC weekly 73.6 to 90.0 kg; 8.8 mg (2 x 0.80 mL) SC weekly

Month(s) Supply*:

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Refills*:

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I certify that the information provided is, to the best of my knowledge current, complete, and accurate and the therapy I have prescribed is medically necessary for this patient and patient's records contain supporting documentation that substantiates the utilization and medical necessity of the therapy. I have discussed A·S·A·P with my patient and my patient would like to be screened for eligibility for A·S·A·P and provided, if applicable, any services under A·S·A·P. I will comply with my own state-specific prescription requirements, such as e-prescribing, state-specific prescription form, fax language. I understand that noncompliance with state-specific requirements could result in outreach to the prescriber. I authorize the provision to patient of ancillary supplies, such as sharps containers and alcohol swabs, to administer the therapy. I acknowledge that the prescription may only be filled by a limited number of specialty pharmacies and prescriber authorizes Ascendis and those acting on its behalf to transmit the prescription electronically, by facsimile, or by mail to the appropriate dispensing specialty pharmacy.

Dispense as written Substitution allowed

Please note that the authorization you are providing is not a valid prescription. In order to complete your patient's enrollment, please submit an e-prescription to our program's pharmacy (NPI: 1619213212), or fax a written prescription to our program at 855-813-2039.

Prescriber Signature*^,†:

Date*:

This field is required.

^†This form cannot be processed without the prescriber's signature

Injection Training Support Authorization A·S·A·P will provide my patient/patient's caregiver with training on the proper administration of YUVIWEL. I am requesting A·S·A·P to coordinate YUVIWEL injection training support for my patient/patient's caregiver. I will receive information on the injection training support that my patient/patient's caregiver has received via the fax number I provided. This order is valid for 1 year.

I do not wish to have my patient/patient caregiver trained by A·S·A·P. By checking this box and opting out of injection training support, I acknowledge that I will assume responsibility and arrangements for YUVIWEL injection training for this patient/patient caregiver.

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Patient Enrollment Form

Enroll a patient in the Ascendis Signature Access Program® (A·S·A·P)

Patient Information Authorization

Patient support services requested:

Insurance and Diagnosis

Medical Assessment

Please provide the following details:

Confirmed FGFR3 mutation

Prescriber Information

Prescription/Dosage and Prescriber Authorization

1.3 mg vial (NDC 73362-201-01)

2.8 mg vial (NDC 73362-202-01)

5.5 mg vial (NDC 73362-203-01)

Training Support Authorization

Review Your Submission

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IMPORTANT SAFETY INFORMATION

WARNINGS AND PRECAUTIONS

Risk of Low Blood Pressure

INDICATION AND USAGE

IMPORTANT SAFETY INFORMATION

WARNINGS AND PRECAUTIONS

Risk of Low Blood Pressure

ADVERSE REACTIONS

SPECIFIC POPULATIONS

Pregnancy and Lactation

Renal Impairment