ONE form to get support with Oriahnn® Complete

Give every UF patient a free trial* of ORIAHNN with Oriahnn Complete

Help her enroll in Oriahnn Complete to activate her free trial

1
Fill out

Download and complete this

with your patient to access a 28-day trial supply, so she has the opportunity to try treatment for free.* Then, you can both decide if continuing ORIAHNN is still the right choice for her.

 

2
Fax

Fax the form to 1-855-662-5355.

An Oriahnn Complete Access Specialist will contact your office with next steps.

3
She's enrolled!

Give your patient the Patient Welcome Sheet.

Starting your patient on the free trial? We’ll call to confirm shipping details.

Get your patients the support they need to start and stay on track with their prescribed ORIAHNN treatment plan

Download the Oriahnn Complete Enrollment & Prescription Form

OR for any enrollment questions call 1-800-ORIAHNN (1-800-674-2466)

Savings and access support

One form gives your patient access to everything Oriahnn Complete has to offer, including:

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Start your patients on their first prescription for free

Once enrolled, a free 28-day trial supply of ORIAHNN will be shipped quickly, directly to her. Then, you can both decide if continuing on ORIAHNN is still the right choice for her.

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Help with access

After the trial period, if your eligible commercially insured ORIAHNN patient experiences an initial delay or denial of coverage, she may still be able to continue to access her prescribed therapy at no charge while coverage is established, for up to 24 months.

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Oriahnn Complete Savings Card

The Oriahnn Complete Savings Card can help your eligible, commercially insured patients pay as little as $5 per month for ORIAHNN.

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Dedicated Access Specialists

  • Access Specialists are an in-person and over-the-phone resource with expertise in options to consider based on each patient’s unique insurance coverage situation.
  • They can educate on payer prior authorization (PA) and appeal processes so you can determine the best access solution.
  • They are a resource with expertise in insurance plan processes at a national, local, and program level.

Questions about the prior authorization process?
Contact your dedicated Access Specialist at 1-800-ORIAHNN (1-800-674-2466)

Access forms

Oriahnn Complete is here to help your patients get timely access to ORIAHNN. Along with requesting information from an Oriahnn Complete Access Specialist, you can download the forms your patients may need to get started.

Instructions are available to provide helpful guidelines and tips for completing the forms.

ORIAHNN Prior Authorization tracker instructions.

Prior Authorization Instructions

ORIAHNN Prior Authorization tracker.

Prior Authorization Tracker Template

ORIAHNN Letter of Medical Necessity template.

Letter of Medical Necessity Sample Template

ORIAHNN Appeal Letter template.

Appeal Letter Sample Template

This information is for informational purposes only and is not intended to provide reimbursement or legal advice. The information presented here does not guarantee payment or coverage.

Questions about the prior authorization process?

Contact your dedicated Access Specialist at 1-800-ORIAHNN (1-800-674-2466)

*The ORIAHNN free trial provides a single 28-day trial supply of ORIAHNN at no cost to new patients residing in the United States with a valid prescription for an FDA-approved indication of ORIAHNN and who enroll in Oriahnn Complete. The trial is intended solely to allow new patients not currently taking ORIAHNN to determine with their healthcare provider whether ORIAHNN is right for them. There is no obligation to continue use of ORIAHNN after the trial has concluded and this program does not guarantee insurance coverage. Eligible patients are limited to one 28-day trial supply and may not re-enroll. The ORIAHNN trial supply will be dispensed only through an AbbVie-authorized pharmacy to the patient’s home address and may not be sold or further distributed. No claims for payment may be submitted to any third party insurance plan for product dispensed by program. AbbVie reserves the right to change or discontinue the trial at any time without notice. The trial is not health insurance and is not a discount, coupon, rebate or financial assistance program. Limitations may apply.

Program is not available to patients receiving prescription reimbursement under any federal, state, or government-funded insurance programs (for example, Medicare [including Part D], Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs programs) or where prohibited by law or by the patient’s health insurance provider. If at any time a patient begins receiving prescription drug coverage under any such federal, state, or government-funded healthcare program, patient will no longer be eligible to participate in program. Available to patients between the ages of 18-63 with commercial prescription insurance coverage who meet eligibility criteria. Eligibility: Patients must be diagnosed with heavy menstrual bleeding related to uterine fibroids, have a valid prescription for ORIAHNN® and participate in a commercial insurance plan that has denied or not yet made a formulary decision for ORIAHNN. Once the patient’s insurance plan has made a formulary decision and established a process for reviewing coverage requests for ORIAHNN, continued eligibility for the program requires the submission of a Prior Authorization prior to the next scheduled dose and appeal of the coverage denial within 180 days. Program provides ORIAHNN at no charge to patients for up to 2 years or until they receive insurance coverage approval, whichever occurs earlier. Offer subject to change or discontinuance without notice. This is not health insurance and program does not guarantee insurance coverage.

Terms and Conditions apply. This benefit covers ORIAHNN® (elagolix, estradiol, and norethindrone acetate capsules; elagolix capsules). Eligibility: Available to patients with commercial prescription insurance coverage for ORIAHNN who meet eligibility criteria. Copay assistance program is not available to patients receiving prescription reimbursement under any federal, state, or government-funded insurance programs (for example, Medicare [including Part D], Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs programs) or where prohibited by law or by the patient’s health insurance provider. If at any time a patient begins receiving prescription drug coverage under any such federal, state, or government-funded healthcare program, patient will no longer be able to use the Oriahnn Complete Savings Card and patient must call Oriahnn Complete at 1-800-ORIAHNN (1-800-674-2466) and stop use of the copay card. Patients residing in or receiving treatment in certain states may not be eligible. Patients may not seek reimbursement for value received from Oriahnn Complete including the copay card from any third-party payers. Offer subject to change or discontinuance without notice. Restrictions, including monthly maximums, may apply. This is not health insurance.