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Teva Shared Solutions for TRUXIMA® (rituximab-abbs) Injection    

 

PH: 888-857-3263

FX: 866-676-4073

 

{{current_date}}

 

SUMMARY OF BENEFITS FOR TRUXIMA

PRESCRIBER INFORMATION

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Office Phone: {{case.bv_summary_view.facility_phone_number}}

Office Fax: {{case.bv_summary_view.facility_fax_number}}

Facility Name: {{case.bv_summary_view.facility_name}}

Site of Care Name (if applicable): {{case.site_of_care.name}}

PATIENT INFORMATION

Patient Name: {{case.patient.first_name}} {{case.patient.last_name}}

Patient DOB: {{case.patient.date_of_birth}}

Shared Solutions ID: {{case.patient.patient_key}}

INSURANCE INFORMATION

Payer Name: {{case.bv_summary_view.primary_payer_name}}

Plan Type: {{case.bv_summary_view.primary_plan_name}}

Effective Date: {{case.bv_summary_view.primary_effective_start_date}}

Policy ID: {{case.bv_summary_view.primary_policy_number}}

Payer Rank: {{case.bv_summary_view.primary_payer_rannk}}

Phone Number: {{case.bv_summary_view.primary_payer_contact}}

BENEFIT RESULTS

TRUXIMA Single-dose Vial for Intravenous Use

Coverage Details

Benefit Details

Formulation

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Coverage

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Strength

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Coverage Reason

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Benefit Type

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Co-Pay/Coinsurance

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Drug Code

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Deductible

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Setting of Care

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Out of Pocket Maximum

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Network Status

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Annual Maximum

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PREFERRED SPECIALTY PHARMACY (SP)

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Phone:

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Fax:

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PRIOR AUTHORIZATION (PA)

TRUXIMA Single-dose Vial for Intravenous Use

PA Required

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Submission Options

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PA Dept. Phone

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PA Dept. Fax

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Approval Number

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Approval Dates

{{case.bv_summary_view.primary_authorization_effective_start_date}} - {{case.bv_summary_view.primary_authorization_end_date}}

 

[notes]

 

 

 

 

 

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