[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-284769-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-284769-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","letter-of-consideration-tezspire-together-co-pay-program","Letter of Consideration - TEZSPIRE Together Co-pay Program","","This document serves as an official Letter of Consideration for the TEZSPIRE Together Co-pay Program, specifically designed for patients who have exceeded the standard 180-day window for submitting co-pay claims. It provides a structured format for patients to document essential information, including patient details, product name, date of service, and EOB specifics. By completing this form and providing supporting documentation, patients can request a review of their late claims. The document outlines necessary requirements for EOB submissions and includes contact information for program assistance, ensuring that practitioners and patients can navigate the reimbursement process despite submission delays. 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is the purpose of this Letter of Consideration?","Question",{"text":63,"@type":64},"This letter is used to request a review of co-pay claims submitted to the TEZSPIRE Together Co-pay Program after the standard 180-day deadline.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What information must be included with the EOB documentation?",{"text":68,"@type":64},"Supporting documentation must include the Payer/Insurance Name, Provider Name, Patient Name, Date of Service, Drug Name or J-Code, Billed Amount, Allowed Amount, and Patient Responsibility.",{"name":70,"@type":61,"acceptedAnswer":71},"How can I contact the TEZSPIRE Together Co-pay Program?",{"text":72,"@type":64},"You can contact the program at 800-818-1770, available Monday through Friday from 9 am to 8 pm ET.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},284769,1790289901,{"code":4,"msg":82,"data":83},"success",[84,89,93,98,103,108,113,117,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social 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Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":114,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":4},962085571259,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","[Note: This is a fillable form that can be used to submit a Letter of Consideration to the TEZSPIRE Together Co-pay Program.]  \nLetter of Consideration for the TEZSPIRE® Together Co-pay Program  \nclaims submitted after 180 days*  \nFax to: TEZSPIRE Together Co-pay Program 800-683-6269  \nPatient First and Last  \nDate:   Name:    \nProduct Name:   Patient Date of Birth:   Date of Service:   Patient Co-pay ID:    \nExplanation of Benefits (EOB)  \nEOB Processed Date:   Claim Amount:    \nI understand that I have exceeded the 180-day requirement for co-pay claims submission, but due to the following, I was not able to submit the claim in a timely manner.  \nPlease see the attached EOB and supporting documentation for consideration.  \nSincerely,  \nName:   Office Name:    \nAddress:   Email Address:    \nPhone Number:    \nEOBs (or supporting documentation) must include the following:  \nPayer/Insurance Name Provider Name Patient Name  \nDate of Service  \nName of Drug/J-Code Billed Amount Allowed Amount Patient Responsibility  \nIf you have any questions, contact the TEZSPIRE Together Co-pay Program at 800-818-1770 MondayFriday 9 am to 8 pm ET.  \n*The TEZSPIRE Together Co-pay Program Terms and Conditions require medical benefit co-pay claims to be submitted within 180 days from the date of approval documented on the EOB. Claims submitted more than 180 days after that date will be reviewed based on the circumstances outlined in the Letter of Consideration and are not guaranteed to be approved.  \nUSA-157-81298","cbCaith6ysWE7Et0","https://ap.wps.com/l/cbCaith6ysWE7Et0","pdf",221319,"English","# Letter of Consideration for the TEZSPIRE Together Co-pay Program\n## Patient and Service Details\n## Explanation of Benefits (EOB) Information\n## Submission Requirements and Contact Information","[{\"question\":\"What is the purpose of this Letter of Consideration?\",\"answer\":\"This letter is used to request a review of co-pay claims submitted to the TEZSPIRE Together Co-pay Program after the standard 180-day deadline.\"},{\"question\":\"What information must be included with the EOB documentation?\",\"answer\":\"Supporting documentation must include the Payer/Insurance Name, Provider Name, Patient Name, Date of Service, Drug Name or J-Code, Billed Amount, Allowed Amount, and Patient Responsibility.\"},{\"question\":\"How can I contact the TEZSPIRE Together Co-pay Program?\",\"answer\":\"You can contact the program at 800-818-1770, available Monday through Friday from 9 am to 8 pm ET.\"}]","Letter of Consideration - TEZSPIRE Together Co-pay Program | PDF",1789629127]