This form is used to enroll a patient in INSUPPORT® services. Start by selecting the service(s) requested by the patient and complete the required steps outlined on the Form. Please ensure that the patient reads, understands, signs, and dates the Patient Authorization page of the Patient Enrollment Form, if required. A Spanish Patient Enrollment Form is also available.
Healthcare Providers may electronically enroll a patient in INSUPPORT® by going to www.insupportportal.com.
Patient Authorization is required for INSUPPORT® to initiate any enrollment request. If the authorization is not completed as part of the Patient Enrollment Form while the patient is in the office, patient authorization may be obtained and submitted electronically by the patient or HCP via the INSUPPORT® Portal. Patients may also download this form, complete it and fax it to INSUPPORT®.
INSUPPORT® cannot provide reimbursement for medical copay claims unless an Enrollment Form or a Certification Form is on file for any patient. If you have not enrolled a patient in the INSUPPORT® Copay Assistance Program for PERSERIS, you must complete this form and submit to INSUPPORT® in order to receive reimbursement for copay claims.
This form will provide additional information on completing an INSUPPORT® Patient Enrollment Form for PERSERIS.
INSUPPORT® can research the patient's insurance benefits for PERSERIS for patients enrolled in Benefit Coverage Information or the Insurance Verification Only Service. This resource provides detailed information about the Benefit Summary from INSUPPORT®.
This sample letter offers examples of full additional information that may be helpful when requesting a reevaluation of a patient's denial for PERSERIS coverage by the insurance provider.
This sample letter offers examples of additional information that may be required by an insurance provider to demonstrate that treatment with PERSERIS is warranted, appropriate, and medically necessary.
Neither INSUPPORT®, nor Indivior Inc., makes any warranties, expressed or implied, about the accuracy of the insurance coverage information, nor is this a guarantee of current or future coverage and/or reimbursement for any Indivior product. Patients and healthcare professionals should always verify actual coverage, coding, patient out-of-pocket costs, and reimbursement guidelines with an insurance provider on a patient-specific basis.
Find an Injection Location
Search the PERSERIS Patient Injection Network (PIN) to find an injection location near your patient that can administer PERSERIS for you.
WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS
Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. PERSERIS is not approved for the treatment of patients with dementia-related psychosis and has not been studied in this population.
Please see the full Prescribing Information including BOXED WARNING and Important Safety Information for PERSERIS.
This form may be used by a healthcare provider to refer a patient directly to a PIN location if not using INSUPPORT®'s Full Program Services.
Find a Field Reimbursement Specialist (FRS)
The Substance Abuse and Mental Health Services Agency (SAMHSA) also provides treatment information. Go to https://findtreatment.samhsa.gov to find a facility near your patient that can provide mental health and/or substance use treatment based on patient-specific criteria. Steps for using SAMHSA's Treatment Services Locator.*
This brochure provides an overview of the INSUPPORT® services.
This brochure provides an overview of the information and processes associated with Transition of Care Support for enrolled patients.
For patients who are transitioning to a new healthcare setting for the treatment of PERSERIS, this card can be given to the patient to provide important information on next steps such as the patient's next injection due date, the new provider's contact information and appointment information, if applicable.
This resource provides an overview of functionality available for HCPs and Patients who use the INSUPPORT® Portal to provide information to INSUPPORT® electronically.
This guide provides information on PERSERIS billing and coding for claims submissions to the patient's insurance provider.
This document provides details about patient eligibility and enrollment requirements as well as the benefits and conditions for the INSUPPORT® Copay Assistance Program for PERSERIS.
This brochure provides healthcare providers with detailed information about the INSUPPORT® Copay Assistance Program for PERSERIS.
INSUPPORT® offers a list of specialty distributors that distribute PERSERIS.
This short video provides an overview of INSUPPORT® and the services it provides.
For the Patient
INSUPPORT® was designed to help facilitate patient access to PERSERIS.
This brochure provides patients and caregivers with detailed information about INSUPPORT®.
This brochure provides patients and caregivers with an overview of information and processes associated with Transition of Care Support for enrolled patients.
This brochure provides patients with detailed information about the INSUPPORT® Copay Assistance Program for PERSERIS.
This is a glossary to help patients understand common insurance terms.
*The Behavioral Health Treatment Services Locator is a third party website that is managed and owned by Substance Abuse and Mental Health Services Administration (SAMHSA). Any information provided by Indivior Inc. and INSUPPORT® regarding this resource is for your convenience and general informational purposes only. Indivior Inc. does not own, manage, operate, endorse, or have any responsibility for or control over any third party websites or the contents contained within, or in any way review, verify, or confirm the contents contained in any such third party websites. Indivior Inc. makes no representation or warranty of any kind whatsoever, including but not limited to, whether third party websites or their contents may in any way be accurate, correct, complete or up-to-date, or that their data protection or data security standards are adequate. You are solely responsible for any and all interactions with any third party websites and the content they provide.