The CRENESSITY enrollment form is a combined prescription and support-program application that your doctor submits to PANTHERx Rare, the specialty pharmacy that fills every CRENESSITY prescription. Once it’s in, the form triggers insurance verification, assigns you a dedicated Care Coordinator, and determines whether you qualify for financial assistance that can reduce your out-of-pocket cost to $0. The signed form is faxed to PANTHERx Rare at 1-855-606-7288, or your prescriber’s office can complete it online through the CoverMyMeds portal.1Neurocrine Biosciences. CRENESSITY Enrollment Form
What the Form Actually Does
Filling out the form does three things at once: it sends the prescription to the pharmacy, it enrolls you in Neurocrine Access Support, and it kicks off a benefits investigation with your insurer. Which assistance track you land in depends on your coverage. Commercial insurance holders are placed in the Savings Program, which is applied automatically at the pharmacy and brings most patients’ copay to $10 or less per month.2Neurocrine Access Support. Financial Support Programs If your coverage is delayed, the QuickStart Program can provide a free 30-day supply so treatment isn’t held up by paperwork.3CRENESSITY. Support and Resources And if you’re uninsured, your plan doesn’t cover CRENESSITY, or you can’t afford it, the Patient Assistance Program (PAP) may supply it at no cost after reviewing the income information you report in Section 3.4Neurocrine Access Support. Financial Support
What to Have Ready Before You Start
The form has sections completed by both the patient (or caregiver) and the prescribing physician. You’ll move faster if you pull these items together before sitting down:
- Your legal first and last name, date of birth, home address, phone, email, and the last four digits of your Social Security number.
- Your pharmacy insurance card. You’ll copy the Rx insurance name, Member ID, BIN, PCN, Rx Group number, the policy holder’s name and date of birth, and the provider call number printed on the card. If you don’t have insurance, you’ll check a box in Section 2 and skip the rest.
- For PAP applicants only: your total monthly gross household income and the number of people in your household. The form doesn’t ask for tax returns or pay stubs, just those two figures.
- For your doctor: the ICD-10 diagnosis code (E25.0 or E25.9), your current steroid dose, weight in kilograms, height, allergies, and any prior therapies, plus the prescriber’s name, NPI, office contact information, and a facility contact person with email.1Neurocrine Biosciences. CRENESSITY Enrollment Form
Filling Out the Patient Sections
Section 1: Patient Information
Enter your legal name, date of birth, address, and the last four of your SSN. Give a phone number and note whether it’s a mobile line and whether you prefer calls or texts, because your Care Coordinator will use that number to schedule deliveries. Select your sex as it appears on file with your insurance, since this affects claims processing; gender identity is an optional separate field. If a caregiver or alternate contact will handle coordination for you, add their name, phone, and relationship.
At the bottom of Section 1 are two signatures. The first is required and authorizes Neurocrine and its partners to access and share your health information for support-program purposes. The second is optional and authorizes pharmacy texting and other outreach. Read the authorization language on page two before signing.1Neurocrine Biosciences. CRENESSITY Enrollment Form
Section 2: Patient Insurance Information
Check the box for your payer type (Commercial, Medicaid, Medicare, Other, or no insurance), then copy the Rx insurance name, policy holder name and date of birth, Member ID, BIN, PCN, Rx Group number, and the provider call number straight from your pharmacy benefits card. Transpose a single digit in the BIN or PCN and the automated benefits check will fail, which delays everything downstream. Double-check the numbers against the card before you move on.
Section 3: Patient Assistance Program
This section applies only if you’re seeking help through the PAP. Confirm that you’re a U.S. resident, then enter your total monthly gross household income and the number of people in your household. Specific income thresholds aren’t published; a Care Coordinator reviews each case individually.4Neurocrine Access Support. Financial Support If you have commercial insurance and expect the Savings Program to cover your costs, leave Section 3 blank.
What Your Doctor Completes
Sections 4 through 7 belong to the prescribing physician. Section 4 captures the diagnosis code, your weight, height, current glucocorticoid steroid dose, known allergies, and previous therapies. Section 5 is the prescription itself: product, dosage, quantity, directions, and refills. A note on the form reminds prescribers that patients facing coverage delays may be eligible for a free limited supply through QuickStart.
Section 6 is prescriber contact information, including a facility contact name and email so the Care Coordinator has someone to call with questions. In Section 7, the prescriber signs and dates the form, certifying that the information is accurate and that CRENESSITY was prescribed based on independent medical judgment. That signature is what authorizes Neurocrine’s support program to run insurance verification and pursue reimbursement on your behalf.1Neurocrine Biosciences. CRENESSITY Enrollment Form
Submitting the Form
Fax is the standard route. The completed, signed form goes to PANTHERx Rare at 1-855-606-7288.1Neurocrine Biosciences. CRENESSITY Enrollment Form Prescribers can also submit it online through the CoverMyMeds portal linked from the Neurocrine Access Support HCP resources page.5Neurocrine Access Support. Neurocrine Access Support for CRENESSITY A downloadable PDF of the form lives at pi.neurocrine.com under the CRENESSITY section, and your doctor’s office can request printed copies.
Doctors who prefer not to use the enrollment form can prescribe CRENESSITY through ePrescribing, a standard faxed prescription, or by calling PANTHERx directly. The enrollment form is still the recommended path, because it activates financial support and insurance coordination at the same time it sends the prescription.6Neurocrine Access Support. Prescribing CRENESSITY Keep a copy of the completed form for your own records.
What Happens After You Submit
Once PANTHERx receives the form, a Care Coordinator is assigned to your case and sends enrollment confirmation to your doctor within one business day.7Neurocrine Access Support. CRENESSITY Patient Journey That coordinator becomes your single point of contact going forward.
Next comes insurance verification. Your Care Coordinator checks whether your plan requires prior authorization and, if so, works with your doctor’s office on the documentation. This step can take a few days or several weeks depending on the insurer. If you have commercial coverage, the Savings Program is applied automatically once the claim processes, so you don’t need to present a separate copay card at the pharmacy.2Neurocrine Access Support. Financial Support Programs
When the prescription is approved and ready, your Care Coordinator calls to schedule delivery to your home, workplace, or another convenient address. CRENESSITY is dispensed exclusively through PANTHERx, so there’s no retail pharmacy pickup.8Neurocrine Access Support. Personalized Support Answer those calls promptly, because missed calls can delay a shipment.
If Your Coverage Is Delayed or Denied
A denial isn’t the end of the process. Neurocrine Access Support provides a sample appeals letter your doctor can customize and submit to your insurer. That template and other office resources are available on the HCP resources page or by calling 1-855-CRNSITY (276-7489) between 8 AM and 8 PM ET, Monday through Friday.5Neurocrine Access Support. Neurocrine Access Support for CRENESSITY Your doctor’s office can also request help from a Neurocrine Regional Patient Access Manager for complex insurance situations.
While an appeal is pending, ask your doctor about QuickStart. New patients experiencing coverage delays can receive a free 30-day supply of CRENESSITY so treatment doesn’t pause.3CRENESSITY. Support and Resources If the appeal fails and you can’t afford the medication out of pocket, the Patient Assistance Program may cover the full cost. Your Care Coordinator can start that application using the income information you already provided in Section 3.