SKYTROFA® now has expanded Medicaid
coverage—help more patients access treatment
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SKYTROFA® is covered with a prior
authorization on most plans
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SKYTROFA® is ready to ship to your patients!
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Benefits Verification

Complete this form to initiate a quick benefits verification. After the form is submitted, the Ascendis Signature Access Program® (A·S·A·P) will contact your patient's insurance provider to verify coverage for SKYTROFA®.

Thank you!

Your Patient’s Benefits and Pharmacy Information has successfully submitted.

Thank you for providing consent for the Ascendis Signature Access Program® (A·S·A·P) to contact your patient's insurance provider to verify their benefits. We will contact you shortly with additional information. Please reach out to us at 1-844-442-7236 with any questions.

Patient Information Authorization Insurance Diagnosis Prescriber Information SKYTROFA® Prescription/Dosage and Prescriber Authorization Review Your Submission
Patient Information Authorization
Insurance
Diagnosis
Prescriber Information
SKYTROFA® Prescription/Dosage and Prescriber Authorization
Review Your Submission

Patient Information Authorization

*Required field.
Please select your patient's growth hormone (GH) treatment experience:*
Additional enrollment instructions:
†For Auto-Injector only, must include evidence of an approved claim by insurance.

Insurance

*Required field.
Please select the appropriate statement:*

Patient Insurance Card (Front)

Patient Insurance Card (Back)

Prior Authorization (PA) Submitted:
PA Approval:

Diagnosis

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

Prescriber Information

*Required field.

SKYTROFA® Prescription/Dosage and Prescriber Authorization:

*Required field.

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

kg
mg

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

By signing below, I certify that: (a) I am a licensed practitioner, in good standing under applicable state law; (b) the information I have provided on this enrollment form is, to the best of my knowledge, true, complete, and accurate; and (c) I have obtained the necessary authorization from the patient, patient's caregiver, and/or legal representative to use, disclose, share, or otherwise release the above information, including the patient's protected health information (“PHI”) for the purpose of providing patient assistance, including verifying insurance coverage, arranging training services, and evaluating patient's eligibility for alternate sources of funding. Further, I appoint the Ascendis Signature Access Program® (“A·S·A·P”), on my behalf, to convey this prescription to the dispensing pharmacy. I will immediately notify Ascendis Pharma if the above-named patient, individually or through their caregiver, and/or legal representative, revokes their consent. I give you permission to contact me, or the above-named patient, patient's caregiver, and/or legal representative.

Please note that the authorization you are providing is not a valid prescription. For additional program services, other than a Benefit Verification, a prescription will be needed. You may submit an e-prescription to our program's pharmacy (NPI: 1699202838), or fax a written prescription to our program at 1-888-436-0193.

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.