Get Needy Meds Form

This guide provides users with a professional and supportive approach to completing the Needy Meds Form online. It aims to ensure clarity and ease throughout the process for individuals seeking assistance.

Follow the steps to successfully complete your application.

1. Use the ‘Get Form’ button to access the Needy Meds Form and open it in your preferred editor.
2. In Section 1, Coverage Support, select one option to indicate your preferred specialty pharmacy from the list provided.
3. Fill out Section 2, Patient Information, with the personal details of the patient, including name, address, contact information, date of birth, and preferred method of communication.
4. Continue to Section 3, Insurance Information, and attach copies of both the front and back of your medical and prescription cards, or indicate if you have no insurance.
5. In Section 4, Prescriber and Rx Information, provide the prescriber’s name, contact information, and prescription details for the medication ® (alirocumab).
6. Complete Section 5, Treatment Information, by filling in LDL-C values, diagnosis codes, and any previous lipid-lowering treatments.
7. In Section 6, Patient Education, indicate if clinical nursing support is required for product administration.
8. For Section 7, Household Income, select your total annual household income to determine eligibility for assistance programs.
9. Review Sections 8 and 9, ensuring you understand and agree to the patient certifications and the authorization to use and disclose health information. Sign and date where indicated.
10. Once completed, save any changes made to the form. You can download, print, or share the form as needed before faxing all 4 pages to MyPRALUENT at 1-844-872-5447.

Complete your Needy Meds Form online today to access the support you need!