Resources to help support you and your patients

ForgingBridges
Start Form

Use this form to prescribe Attruby for your appropriate patients and enroll them in the ForgingBridges Support Program

ForgingBridges Patient
Consent Form

Your patient may sign this standalone Patient Consent Form OR the patient section within the Attruby Start Form above to enroll in ForgingBridges

PA & Appeals
Checklist

The checklists below provide information and tips that may be useful when writing letters to obtain treatment authorization for Attruby or to appeal a decision from your patient’s insurance plan if an authorization for Attruby is denied.

Annotated
Sample Coverage
Determination Form

The information in this resource provides tips for submitting a coverage determination request related to Attruby on behalf of your patient with Medicare Part D prescription drug coverage.

Sample Letter of
Medical Necessity &
Exception

This sample letter contains suggestions for the type of information to consider when a letter of medical exception or necessity to a patient’s insurance provider may be appropriate. Any letter of medical exception/ necessity should be based on your medical judgment and discretion.

Sample Letter of PA
Denial Appeal

This sample letter contains suggestions for the type of information to consider when a letter of appeal to a patient’s insurance provider is appropriate. Any letter of appeal should be based on your medical judgment and discretion.

Medicare Part D Guide
for Patients

Educates patients with Medicare Part D on the Medicare Prescription Payment Plan and eligibility for low-income subsidy

Commercial Copay
Assistance Program
Brochure

Provides your patients with information about the ForgingBridges Copay Assistance Program