SKYTROFA® is covered with a prior
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Auto-Injector Enrollment

Complete this form for Auto-Injector fulfillment through the Ascendis Signature Access Program® (A·S·A·P) for patients who have an approved claim by their insurance company.

Thank you!

The Auto-Injector Enrollment form has successfully submitted. Our program will contact the patient and caregiver to confirm shipment information prior to delivery.
In order to complete the shipment of the SKYTROFA® Auto-Injector, we will contact your patient's insurance to confirm an approval is on file.
Patient Information Insurance Information Diagnosis Code Prescriber Information SKYTROFA® Prescription/Dosage and Prescriber Authorization Review
Patient Information
Insurance Information
Diagnosis Code
Prescriber Information
SKYTROFA® Prescription/Dosage and Prescriber Authorization
*Required field.
Please select your patient’s GH treatment experience:*

Patient Information

Caregiver Information

*Required field.

Primary Medical Insurance

Pharmacy/Rx Insurance

Patient Insurance Card (Front)

Patient Insurance Card (Back)

*Required field.
Please check the applicable ICD-10 diagnosis code. Pediatric GHD:*
*Required field.
*Required field.

Recommended weight-based dosing ranges are based on 0.24 mg/kg/week.

kg
mg SKYTROFA®

The SKYTROFA Auto-Injector is packaged in a separate carton.

PRESCRIBER AUTHORIZATION: Prescriber certifies that he/she has obtained consent to release the patient’s health information to A·S·A·P in conjunction with the services working solely on behalf of the patient for the purposes of seeking reimbursement through A·S·A·P; verifying insurance coverage; arranging for nursing services; and evaluating the patient’s eligibility for alternate sources of funding, patient support services, and materials and product fulfillment via Specialty Pharmacies. The prescriber is to comply with his/her state-specific prescription requirements such as e-prescribing, state-specific prescription form, fax language, etc. Noncompliance with state-specific requirements could result in outreach to the prescriber. I authorize A·S·A·P to transmit this prescription to the appropriate pharmacy designated by the patient utilizing their benefit plan.

Please note that the authorization you are providing is not a valid prescription.

Review your submission

Please click the Review button below if you wish to check the accuracy of the information provided. When ready, click the Submit button. A confirmation message will appear when the form has successfully submitted.