Download the latest Prescription and Service Request (PSR) Form for your practice now.

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A TRUSTED APPROACH TO PATIENT ADHERENCE AND SUPPORT

For more than 20 years, Teva’s Shared Solutions® has partnered with your practice and your patients, helping them start and stay committed to therapy.

Prescription and Service Request (PSR) Form

Submitting up-to-date COPAXONE® Prescription & Service Request Forms is the first step for your patients to receive adherence and educational support from Teva's Shared Solutions® during their COPAXONE® therapy.

  • When prescribing COPAXONE®, both new prescriptions and refills, download the latest Prescription & Service Request Form.
  • Your patient (or authorized representative) must read, sign, and date the Patient Authorization section.
  • In the Prescriber Signature section, indicate Dispense as Written (DAW) to help ensure your patients receive COPAXONE® as prescribed, rather than a generic option, from the pharmacy.
  • Submit completed forms via fax to 1-800-775-5834.

Call Teva's Shared Solutions® at 1-800-887-8100 to request Prescription and Service Request Form tear pads and other patient resources.

SEE AVAILABLE RESOURCES

Letter of Medical Necessity

A template of a letter payers may require to establish medical necessity.

DOWNLOAD TEMPLATE

Appeals Letter

A template of a letter payers may require to appeal a denial of coverage.

DOWNLOAD TEMPLATE

Patient training and adherence support

Compassionate, professional nurse support helps patients stay compliant throughout their therapy experience.

  • Injection training: Teva-trained nurses provide free, in-home, 1-on-1 injection training when starting or switching to COPAXONE®. Sessions address proper injection technique, injection site rotation, and tips to help manage ISRs and maintain healthy skin.
  • Learn more on the COPAXONE® patient site.
  • Phone support: Teva nurses are available for personalized phone guidance and support. COPAXONE® patients may speak to a nurse by calling 1-800-887-8100.
  • COPAXONE iTracker® 2.0: The improved mobile app for Apple® and Android helps patients track their injections, manage injection site rotation, and stay committed to therapy. Features include:
    • Injection calendar with personalized reminders
    • Injection site rotation tracking and guidance
    • Journal for recording and organizing injection notes
    • Direct connection to Teva’s Shared Solutions® phone support
    • Video injection tutorials and helpful tips
  • Learn more on the COPAXONE® patient site, and suggest your patients download COPAXONE iTracker® 2.0 from the App Store® or Google Play.
  • autoject®2 for glass syringe: Available free with a prescription through Teva's Shared Solutions®. This device hides the needle and delivers therapy with a light button press.

For questions or to request any of Teva’s Shared Solutions® services, have your patients call 1-800-887-8100 or visit COPAXONE.com.

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