When using the Enrollment Form, please note that 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.
Once you identify an appropriate patient who may benefit from BESREMi (ropeginterferon alfa-2b-njft), you can call us at 800-700-5053 or 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 .
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.
to speak with one of our PharmaEssentia SOURCE Case Managers between 8:00 AM and 8:00 PM ET, Monday through Friday.
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BESREMi, the BESREMi logo, and
PharmaEssentia are registered trademarks of PharmaEssentia
Corporation, and the PharmaEssentia logo, PharmaEssentia SOURCE,
and the PharmaEssentia SOURCE logo are trademarks of
PharmaEssentia Corporation. US-BSRM-2100061 (v6.0)
12/2022
800-700-5053
