Forms and Documents for VESIcare
We've provided a number of different forms and letters to help you.
Forms for Benefit Verification and Patient Assistance Requests are no longer available on this site. For your convenience Benefit Verification Requests and Patient Assistance Requests can now be submitted conveniently online via Astellas eService or via fax to 1-866-317-6235.
If you don't see a form you need, please contact us at 1-800-477-6472.
Astellas Forms
- Benefit Verification Request Form (PDF - 60 KB)
- Patient Authorization to Disclose Health Information (HIPAA) (PDF - 123 KB)
- Sample Letter of Denial Appeal (PDF - 40 KB)
- Sample Letter of Medical Necessity (PDF - 40 KB)
- Sample Letter of Medicare Carrier Advisory Letter (PDF - 40 KB)
- VESIcare Astellas Access Program Application (PDF - 44 KB)
Other
- Community Care RX Criteria For VESIcare (PDF - 1.1 MB)
- Community Care RX Request For a Lower Co-Pay (Tiering Exception) Form (PDF - 677 KB)
- Community Care RX Request For Quantity Limit Exception Form (PDF - 1.0 MB)
- Community Care RX Request For Step Therapy Exception (PDF - 949 KB)
- Humana PDP Prior Authorization Form (PDF - 373 KB)
- Kentucky Spirit Managed Medicaid Prior Approval Form (PDF - 39 KB)
- Model Coverage Determination Request Form (PDF - 336 KB)
- NY Managed Medicaid - Amerigroup Prior Approval Form (PDF - 260 KB)
- NY Managed Medicaid - CDPHP Prior Approval Form (PDF - 25 KB)
- NY Managed Medicaid - Fidelis Prior Approval Form (PDF - 76 KB)
- NY Managed Medicaid - Metroplus Prior Approval Form (PDF - 336 KB)
- Presbyterian Pharmacy Exception Review Request Form (PDF - 37 KB)
- Universal American (UAFC) Request for Coverage of a Non Formulary Drug form (PDF - 236 KB)
- WellCare Medicare Coverage Determination Request Form (PDF - 421 KB)
Some forms and documents provided on this Web site are not the property of Astellas Pharma US, LLC, and may be subject to change.
