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Forms & Resources

Tools and forms to assist with patient access and support for TURALIO

Helpful Resources - TURALIO HCP

Patient Enrollment Form

When sent along with the prescription, this form allows Biologics to determine coverage and assess eligibility for financial assistance programs. This form requires a patient’s or representative’s signature.

Sample Letter of Medical Necessity

Sample Letter of Appeal

Prior Authorization Checklist

Visit the TURALIO REMS Program website

TURALIO is only available through a restricted program under a REMS because of the risk of hepatotoxicity. Prescribing physicians should visit or call 1-833-887-2546 for information on the program.

The completion and submission of coverage-related documentation are the responsibility of the patient and healthcare provider. Daiichi Sankyo, Inc., makes no representation or guarantee concerning coverage or reimbursement for any service or item. A completed form includes signatures from both the physician and the patient. Before submitting, please ensure all required information is provided.