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Forms & Resources

Helpful Resources Are at Your Fingertips

Here you will find forms and helpful resources for PharmaEssentia SOURCE and BESREMi all in one place.

Enrollment Form

Complete the Enrollment Form with your patient and fax it to 800-700-5065.

Once enrolled and ready for treatment, patients will receive a Welcome Kit that includes important information to get them started on BESREMi.

Product Fact Sheet and Ordering Information

Explore product information about BESREMi, including our specialty pharmacy and distribution network, as well as storage and handling instructions.

PharmaEssentia SOURCE HCP Guide

How to start your patients on BESREMi

Sample Letter of Medical Necessity

Verify that the medication you are prescribing is for the treatment of your patient’s disease.

Medical Necessity Travel Form

Explain why it is medically necessary for your patient to take BESREMi with them when they fly.

Sample Letter of Appeal

Request a reconsideration after a PA denial.

Sample Formulary Exception Letter

Request that a formulary restriction placed on BESREMi be removed, as it is medically appropriate and necessary for your patient’s treatment.

PharmaEssentia SOURCE Patient Guide

Let your patients know about the comprehensive services and support available to them.


Instructions for Use

Review the steps involved in the BESREMi injection process.



Watch step-by-step instructions on how to inject BESREMi.

Still have questions? Call our dedicated PharmaEssentia SOURCE Nurse Case Managers at 800-700-5053 between 8:00 AM and 8:00 PM ET, Monday through Friday.