The TAKHZYRO Start Form acts as your patient's prescription for TAKHZYRO. It also allows your patient to authorize Takeda to provide Takeda Patient Support services (eg, access to a support specialist and at-home injection training).

TAKHZYRO Start Form DOWNLOAD EMAIL

TAKHZYRO Annotated Start Form DOWNLOAD EMAIL

The TAKHZYRO Start Form requires:

• Patient name and contact details: Include the patient's full contact information, including email address and phone number. Also include your patient’s full name at the top of each page where indicated
• Prescriber signature: Review and consent to the prescriber certifications
• Dosage check box: Select 1 starting dosage for new patients
• Takeda Patient Support enrollment: Remind your patient to check this box to enroll in Takeda Patient Support and receive product support services such as one-on-one support with a support specialist, free injection training, and financial assistance
• Patient signature: Your patient needs to review and consent to the patient authorization, which is critical for allowing Takeda Patient Support to begin a benefits investigation without delay

The Quick Start Program allows patients with commercial insurance* to receive up to 2 months' supply of TAKHZYRO at no cost while full benefits are being verified.

TAKHZYRO Quick Start Form DOWNLOAD EMAIL

Important guidance when completing the Quick Start Form:

• Ensure your patient's Starting Dosage corresponds to the dosage selected in Section 4 of the TAKHZYRO Start Form
• The prescriber's signature is required. Stamps are not acceptable

*Patients on Medicare or Medicaid are not eligible for the Quick Start Program; please have your patient contact their Takeda Patient Support representative to discuss other financial options that may be available to them.

Complete the prescription submission by faxing the TAKHZYRO Start Form and the TAKHZYRO Quick Start Program: Enrollment Form to Takeda Patient Support at 1-855-663-7284. Takeda Patient Support will begin the benefits investigation process and let your office know of any next steps.

Getting Started with TAKHZYRO Brochure DOWNLOAD EMAIL

Let your patient know what to expect next:

• If your patient consented to Takeda Product Support, let them know that a support specialist will call them within 2 to 4 days. Ask your patient to answer the call and save the Takeda Patient Support number (1-866-888-0660) to their phone to avoid spam blockers
• Additional HAE resources are available for patients to download
• To help your patient understand next steps, provide them with the Getting Started with TAKHZYRO Brochure

Generally, a prior authorization (PA) will be required for treatment to begin, and Takeda Product Support may contact your office to share additional information that will help you complete this process. Refer to the Benefits Verification Checklist for a list of the necessary information your patient may need when submitting a PA.

Benefits Verification Checklist DOWNLOAD EMAIL