Patient Enrollment Form

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XTANDI Access ServicesSM

Astellas has developed an integrated approach of customized access and reimbursement services to help you and your patients minimize potential barriers to accessing XTANDI. Eligibility rules may apply. Please contact XTANDI Access ServicesSM for more information.

XTANDI Access ServicesSM includes case management specialists and a network of specialty pharmacies all working together to ensure rapid patient access to XTANDI. XTANDI Access ServicesSM is available to providers, whether you dispense out of your office-based pharmacy or refer patients directly to a specialty pharmacy in the authorized XTANDI network. Support is available whenever you need it.

Our goal is to help you and your patients access XTANDI. No matter how you decide to secure XTANDI for your patients, Astellas is here to support you.

XTANDI Access ServicesSM offers an array of resources to help facilitate product coverage and payment, and to ensure that your patients can access XTANDI. XTANDI Access ServicesSM can:

  • answer your questions about reimbursement, coverage, and payment for XTANDI;
  • verify patient insurance coverage and cost sharing for XTANDI;
  • help you and your staff verify insurance requirements and track prior authorizations;
  • provide assistance to you and your staff when prior authorizations are denied or when a patient's insurer does not cover XTANDI;
  • help you coordinate with a specialty pharmacy within our network that is contracted with your patients' insurers to dispense XTANDI;
  • determine whether your patients are eligible for patient or financial assistance for out-of-pocket costs associated with XTANDI;
  • provide you with 24/7 access to status updates on your requests for patient assistance via our eService at www.astellasaccess.com;
  • direct your patients to additional information about XTANDI treatment.

XTANDI Access ServicesSM provides assistance with access-related issues throughout the entire treatment process, from the moment that you prescribe XTANDI until prescription fulfillment.

To enroll your patient in XTANDI Access ServicesSM, please complete the Patient Enrollment Form in its entirety (required fields marked with an asterisk), including the Signatures section, and return via fax to 1-855-982-6341. The completed Signature section allows XTANDI Access ServicesSM to do the following:

  • Perform the necessary service(s) to assist with patient access to XTANDI
  • Triage the completed prescription(s) to a specialty pharmacy in the XTANDI Access ServicesSM network
  • View patient's Personal Health Information, including a patient's financial information to determine the most appropriate form of financial assistance as appropriate