INITIATING ADEMPAS TREATMENT

Before you can get your patients started with Adempas, you must fill out the forms found below. Within the Adempas Prescription Form, your patients may choose to enroll in the Aim Patient Support Program for support throughout their treatment journey.

FORMS TO GET YOUR PATIENTS STARTED
enrollment form 1
ADEMPAS PRESCRIPTION AND PATIENT SUPPORT PROGRAM ENROLLMENT FORM

All patients must sign and date the form to receive any Bayer services or communications. Patients can choose to opt in to allow information to be shared with third parties such as pharmacies, insurance companies, and Bayer. The optional patient consent allows patients to take advantage of the Aim Patient Support Program resources. They can still take Adempas if they do not opt in, but they will not receive any myAim or other communications.

enrollment form 2
ADEMPAS REMS PATIENT ENROLLMENT AND CONSENT FORM — FEMALES ONLY

The Adempas REMS is a program to tell patients and healthcare providers about the serious risks of birth defects while taking Adempas. This program is required by the Food and Drug Administration. All females must enroll in this program to receive Adempas. Obtain female patient signature and date, as the enrollment form CANNOT be processed without female patient signature.

REMS=Risk Evaluation and Mitigation Strategy

enrollment form 3
ADEMPAS HOSPITAL PROGRAM CHECKLIST

This form is only for patients who begin treatment in the hospital. Once you have enrolled them, a specialty pharmacy rep will help set up continued treatment with Adempas after discharge. If your patients want this service, they will need to sign their consent before you submit the form.

QUICK START GUIDE TO ENROLLMENT
  All Patients

ALL PATIENTS

Female

FEMALE PATIENTS

Hospital

HOSPITAL PATIENTS

1. Fill out the Adempas
Prescription and Patient Support
Program Enrollment Form.
In addition to the Adempas
Prescription and Patient Support
Program Enrollment Form, fill out
the Adempas REMS Form.
Fill out the Adempas
Hospital Program Checklist
Enrollment Form.
2. Make sure patients sign
and date the form.
Make sure patients sign
and date the forms.
Make sure patients sign
and date the form.
3. Use the prescription form
to enroll in the Aim Patient
Support Program, if desired.
Use the prescription form
to enroll in the Aim Patient
Support Program, if desired.
To enroll, fax the completed
form, along with the
patient’s insurance card,
to the fax number below.
4. Submit according to instructions
below, and remember to
include a copy of the
patient’s insurance card.
Submit according to instructions
below, and remember to
include a copy of the
patient’s insurance card.
A specialty pharmacy rep
will contact patients to set up
shipments of the medication
to their home.

 

ALL PATIENTS
ALL PATIENTS
  1. Fill out the Adempas Prescription and Patient Support Program Enrollment Form
  2. Make sure patients sign and date the form.
  3. Use the prescription form to enroll in the Aim Patient Support Program, if desired.
  4. Submit according to instructions below, and remember to include a copy of the patient’s insurance card.
female
FEMALE PATIENTS
  1. In addition to the Adempas Prescription and Patient Support Program Enrollment Form, fill out the Adempas REMS Form.
  2. Make sure patients sign and date the forms.
  3. Use the prescription form to enroll in the Aim Patient Support Program, if desired.
  4. Submit according to instructions below, and remember to include a copy of the patient’s insurance card.
HOSPITAL PATIENTS
HOSPITAL PATIENTS
  1. Fill out the Adempas Hospital Program Checklist Enrollment Form.
  2. Make sure patients sign and date the form.
  3. To enroll, fax the completed form, along with the patient’s insurance card, to the fax number below.
  4. A specialty pharmacy rep will contact patients to set up shipments of the medication to their home.
ENROLL ONLINE AND BEGIN TREATMENT
Enroll online
ENROLL ONLINE

Online enrollment is fast and secure—simply fill out the forms and sign electronically. Please note, the e-signature process requires both prescriber and patient email addresses. Start the online enrollment process below. Or, if you are new to the e-signature process, download an instructional brochure.

Envelop
OTHER WAYS TO ENROLL

Submit your forms to the Hub via fax (1-855-662-5200), email, or the physician portal.

For more information, call toll-free: 1-855-4ADEMPAS (1-855-423-3672).

MORE IMPORTANT SAFETY INFORMATION LESS IMPORTANT SAFETY INFORMATION

Patient Enrollment