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How to fill out Enrollment Form for CABENUVA (cabotegravir 200 mg/mL; rilpivirine 300 mg/mL) extended-release injectable suspensions 

 

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Filling out the CABENUVA Enrollment Form is the first step to getting your patients ViiVConnect services and support while they are receiving CABENUVA.

 

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ViiVConnect Provider Portal

Enrollment Form.

 

ANNOUNCER: 

You can enroll patients on the ViiVConnect Provider Portal or download the CABENUVA Enrollment Form PDF from ViiVConnect.com. If you download the PDF, you can fill it out on your computer or print it and fill it in by hand. 

 

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Enrollment in ViiVConnect is not required  for your patients to access their prescribed CABENUVA.

 

ANNOUNCER: 

In this video, we'll focus on the printed form and take a closer look at the information you'll need to provide.

 

ANNOUNCER:  

In order for your patient to receive ViiVConnect services for CABENUVA, a benefits verification is necessary. To have ViiVConnect perform the benefits verification, check the Full Benefits Verification Support box. If you will verify benefits yourself, check Limited Benefits Verification Support. If neither box is checked, you will receive full benefits verification support.

 

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Section 1 

Patient Information

 

ANNOUNCER:  

When filling out the patient information section, be sure to complete the current medications, drug allergies, and previous ARV therapies sections so that the Enrollment Form can be used as a prescription for CABENUVA, if your state allows it.

 

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Section 2 

Prescriber Information

 

ANNOUNCER:  

If you’re using the electronic PDF form, you can fill out the prescriber information section and save it as a template to avoid duplicating work for future enrollments.

 

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Section 3 

Prescription Information

 

ANNOUNCER:  

In most states, the Enrollment Form can also act as the prescription for CABENUVA. If it does not meet the requirements in your state or your practice, make sure to attach a prescription to the Enrollment Form. Check the appropriate boxes according to where your patient is in their CABENUVA treatment plan. You can also select the number of refills you would like to authorize.

 

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Section 4 

Oral Shipment Information

 

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The one-time oral supply can be shipped to your office or your patient's home. Check the appropriate box and fill in the shipping address.

 

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Prescriber Declaration Section

 

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Make sure to sign and date the prescriber declaration at the bottom of page 1 so the form can be processed without delay.

 

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Section 5 

Injection Administration Location

 

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Patients may visit your office for CABENUVA, but if a patient has difficulty getting to your office, CABENUVA can be administered at another location. Check "Unknown" if you need assistance in finding an appropriate location. 

 

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Section 6 

Injection Acquisition Information

Specialty Pharmacy

Buy & Bill

 

ANNOUNCER:  

This section lets you specify whether you will acquire CABENUVA from a specialty pharmacy or via Buy and Bill from a specialty distributor. Remember, this decision is often dictated by your patient’s insurance, so if you're not sure, check "Unknown/Undecided," and you can make the decision after benefits verification.

 

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Section 7

Insurance Information

 

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Make sure to complete all of the insurance information in section 7 and include a copy of both sides of the patient’s insurance card and prescription card if available.

 

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Benefits Verification

 

ANNOUNCER:  

If you chose Full Benefits Verification Support at the top of page 1, ViiVConnect will perform a benefits verification and can contact your office or your patients with the results.

 

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If you chose limited Benefits Verification Support, be sure to enter all the requested information in the blue area at the bottom of section 7.

 

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Section 8

Patient Assistance Program

 

ANNOUNCER:  

Section 8 is for eligible patients who need to apply for no-cost medication through the Patient Assistance Program. Make sure your patient provides this information if necessary.

 

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Patient Authorization and Release

 

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You and your patient should review the Patient Authorization on pages 3 and 4 and answer questions A, B, and C on page 4 as well before moving to the patient signature section on page 5. The patient's signature is required in order to complete their enrollment in ViiVConnect.

 

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Patient Representative

A person (not a family member or friend) who is designated to act on the patient's behalf for specific healthcare needs or program requirements.

 

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If they choose to authorize a patient representative, include that information here.

 

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If you submit an enrollment form to ViiVConnect without the required patient signature, let your patient know that they can provide their signature electronically on the ViiVConnect website by choosing eSign from the For Patients menu on the home page and clicking the "Review and Sign Electronically" link to complete the eSignature.

 

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By Fax 

1-844-208-7676

By Mail

ViiVConnect Enrollment

PO Box 220100 

Charlotte, NC 28222-0100

 

ANNOUNCER:  

Now your form is complete and ready for you to fax or mail it to ViiVConnect Enrollment.

 

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Access Coordinator

Field Reimbursement Manager

Access Coordinator

(toll-free) 

1-844-588-3288

Monday-Friday, 8AM-11PM (ET)

 

ANNOUNCER:  

If you have any questions about filling out the CABENUVA Enrollment Form, a ViiVConnect Access Coordinator or your Field Reimbursement Manager can provide you with one-on-one assistance.

 

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Trademarks are owned by or licensed to the ViiV Healthcare group of companies. 

©2021 ViiV Healthcare or licensor. CBRVID200010 September 2021 Produced in USA.