Guidelines and Forms

Thyrogen is covered by Medicare, Medicaid and most private insurance plans. Depending on the individual plan, Thyrogen is sometimes covered as a medical benefit and sometimes as a pharmacy benefit. The ThyrogenONE program will assist you and your patients with understanding the specific requirements of your patients' benefits.

Occasionally, additional documentation is needed in order to obtain prior authorization for reimbursement of Thyrogen. Once you have registered with the program, a ThyrogenONE specialist will provide the appropriate forms and contact information.

The directory below provides information on the ordering and billing process and sample forms and letters to help facilitate the claims process.

Thyrogen Billing Information:

Thyrogen Ordering and Billing Process
Step-by-step instructions and flowchart for the ThyrogenONE process.

Thyrogen Billing Guide
Instructions for physician offices and hospitals on billing for Thyrogen.

Coding Reference Guide
A coding reference for rhTSH-related services.

Sample Forms and Letters:

Statement of Medical Necessity
Some insurers may require additional information to justify the necessity of Thyrogen. This form is designed to give details on why Thyrogen should be administered.

Physician Letter of Medical Necessity
A model letter for a physician requesting prior authorization for Thyrogen from an insurance company.

CMS 1500 Health Insurance Claim Form
A sample health insurance claim form.