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Getting Patients Started

Enrolling Your Patients Is Easy

Complete, sign, and date the healthcare professional portion.

Have your patient complete, sign, and date their portion.

Fax the completed form to 800-700-5065.

Please note: Your signature and your patient’s signature are both required to enroll in PharmaEssentia SOURCE. If your patient is not available to sign, PharmaEssentia SOURCE can follow up with them by phone to obtain their consent once you’ve submitted the Enrollment Form.

Complete the Enrollment Form

Once you identify an appropriate patient who may benefit from BESREMi (ropeginterferon alfa-2b-njft), you can download a PharmaEssentia SOURCE Enrollment Form to get started.

Our dedicated PharmaEssentia SOURCE Case Managers will work with you and your patient to ensure they understand their insurance coverage, are provided with financial assistance options, and get the support they need to begin treatment.

The completed Enrollment Form can serve as your patient’s first BESREMi prescription. If there is an insurance delay, this form also contains a prescription for a temporary supply of BESREMi .

We’re Here to Help

When you enroll your patients in PharmaEssentiaSOURCE, they’ll receive ongoing personalized support while taking BESREMI, including help understanding their insurance coverage and with injection training and titration support.

Call us at 800-700-5053

to speak with one of our PharmaEssentia SOURCE Case Managers between 8:00 AM and 8:00 PM ET, Monday through Friday.

Find out how we can help your patients navigate the access and reimbursement process imgimg