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  • Lynparza Service Request Form And Prescription - Access 360

Get Lynparza Service Request Form And Prescription - Access 360

HOW TO ORDER LYNPARZA Service request form and instructions instructions FOR COMPLETING the service request form and prescriptions PATIENT AND PRESCRIBER INFORMATION omplete the Patient and Health.

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LYNPARZA is part of a proven 2-step plan to help keep your advanced ovarian cancer from growing or returning after platinum-based chemotherapy. LYNPARZA does not work in everyone.

A) Individual is ≥ 18 years of age; AND B) Individual has a germline BRCA-mutation as confirmed by an approved test; AND C) Individual has progressed on two or more prior lines of chemotherapy.

LYNPARZA has serious risks that may lead to death. These include bone marrow problems called Myelodysplastic Syndrome (MDS) or Acute Myeloid Leukemia (AML), lung problems (pneumonitis), and blood clots (venous thromboembolic events [VTE]).

LYNPARZA is a prescription medicine used to treat adults who have: advanced ovarian cancer, fallopian tube cancer, or primary peritoneal cancer with a certain type of inherited (germline) or acquired (somatic) abnormal BRCA gene.

The cost for Lynparza oral tablet 100 mg is around $8,374 for a supply of 60 tablets, depending on the pharmacy you visit. Quoted prices are for cash-paying customers and are not valid with insurance plans. This price guide is based on using the Drugs.com discount card which is accepted at most U.S. pharmacies.

100% of Medicare prescription drug plans cover this drug.

This can be done by the pharmacy or by calling an Access 360 representative. Once enrolled, you will continue to pay a set amount of your out-of-pocket costs for LYNPARZA. The pharmacy will use the Co-pay Savings Program to cover the balance, up to the program maximum.

Access 360 General Patient Authorization Form (PAF) This brief form, once completed, gives Access 360 the ability to provide select services to you. Available in English and Spanish. The Access 360 General Patient Authorization Form must be signed for you to utilize Access 360 support.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232