CABENUVA (cabotegravir 200 mg/mL; rilpivirine 300 mg/mL) EXTENDED-RELEASE INJECTABLE SUSPENSIONS: CABENUVA ENROLLMENT FORM

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The CABENUVA Enrollment Form has sections for providers and patients to fill out together. Enrollment in ViiVConnect is not required for patients to access their prescribed CABENUVA. Here’s some of the information you’ll need to complete the form:

For Healthcare Providers

Prescriber Information

Including name, contact information, Tax ID, State License #, and Prescriber/Group NPI

Prescription Information

Including the prescription/schedule and diagnosis code

Medication Shipment Information

Including address for shipment 

Alternative Site for Administration (ASA) Information

Including ASA and acquisition method (Buy & Bill/Specialty Distributor or Specialty Pharmacy)

For Patients

Patient Information

Including name, date of birth, contact information, and a list of current medications

Insurance Information (if applicable)

Including medical insurance and prescription drug plan information

For Patients Applying for Assistance

If a patient doesn't have insurance and is having trouble paying for the ViiV Healthcare medicine/s, the patient may qualify for the Patient Assistance Program (PAP). To see if a patient may be eligible for PAP, review program requirements.

Patient Signature

A patient signature is required for ViiVConnect enrollment. Patients can add their signature when filling out the form with their healthcare provider or subsequently by adding a Patient eSignature.

Complete, Sign, and Submit the
CABENUVA Enrollment Form

For assistance, please call to speak live with an Access Coordinator at 1-844-588-3288 (toll free), or access secure click-to-chat messaging on the ViiVConnect Portal, Monday - Friday, 8AM - 11PM (ET).

Once the enrollment form has been received, an Access Coordinator may contact patients and providers to review patient benefits for prescribed ViiV medicine and eligibility for financial savings programs. Access Coordinators can also schedule delivery of medication.

A patient signature is required to enroll in ViiVConnect programs. If you are unable to manually sign, use this link to authorize an electronic signature if an enrollment form was submitted previously without one.

NEED HELP? TALK ONE-ON-ONE LIVE WITH OUR ACCESS COORDINATORS   
1-844-588-3288 (toll free)

We have programs for eligible patients who are insured, underinsured, and uninsured. 
Monday - Friday, 8AM - 11PM (ET).
Multilingual options available.

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