LEQVIO (inclisiran) Provider Claim Reimbursement Request 2026

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The document is a reimbursement request form for the LEQVIO® (inclisiran) Co-pay Program, detailing the process for healthcare providers to submit claims for patient out-of-pocket expenses. It outlines eligibility criteria, required documentation, payment methods, and limitations on reimbursement, specifically excluding patients covered by federal health programs. The form must be completed per physician and site, with a certification statement confirming the accuracy of the information provided.

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How to use or fill out LEQVIO (inclisiran) Provider Claim Reimbursement Request

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Click ‘Get Form’ to open it in the editor. This will allow you to access the LEQVIO Provider Claim Reimbursement Request form seamlessly.
Begin by filling out the Health Care Provider Information section. Ensure that all fields marked in bold are completed accurately, including your last name, first name, NPI, and site details.
Next, indicate the preferred method of payment by selecting either 'Check' or 'EFT'. Remember that this choice will apply to all future payments unless you submit a new form.
After completing the form, gather the required documents such as the Explanation of Benefits (EOB) and any necessary CMS forms. These must be faxed to 1-908-548-9364 for processing.
Finally, review your entries for accuracy and sign at the bottom of the form. This certification confirms that all information is correct and complies with program eligibility criteria.

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How do I get help paying for LEQVIO?

You can sign up for the LEQVIO Co-pay Program directly by visiting start.leqvio.com or calling us at 1-833-LEQVIO2 (1-833-537-8462). Data on file. LEQVIO Coverage and Affordability. Novartis Pharmaceuticals Corp; 2024.

What is a covered diagnosis for LEQVIO?

U.S. Food and Drug Administration (FDA)-Approved Indications Leqvio is indicated as an adjunct to diet and statin therapy for the treatment of adults with primary hyperlipidemia, including heterozygous familial hypercholesterolemia (HeFH), to reduce low-density lipoprotein cholesterol (LDL-C).

How to get Leqvio covered?

LEQVIO may be covered if you have traditional Medicare coverage (red, white, and blue card), also called Medicare Part B. You wont have to wait for your doctor to get approval from your health plan.

What is the FDA approved diagnosis for Leqvio?

Leqvio is an injectable prescription medicine indicated as an adjunct to diet and exercise to reduce low-density lipoprotein cholesterol (LDL-C) in adults with hypercholesterolemia, including heterozygous familial hypercholesterolemia (HeFH).

What is the ICD code for Leqvio?

01/04/2022 Select Review: Add clinical criteria and quantity limit for Leqvio. Coding Reviewed: Added HCPCS J3490. All diagnoses pend. Effective 7/1/2022 Added HCPCS J1306.

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Does LEQVIO require prior authorization?

Leqvio is a physician-administered drug that requires clinical PA (prior authorization) .

How to bill for LEQVIO?

LEQVIO billing and coding information Healthcare Common Procedure Coding System level II code1,2 J1306 - Injection, inclisiran, 1 mg. Billing units: 284. JZ modifier: Effective providers and suppliers are required to report the JZ. modifier on all claims that bill for drugs from single-dose containers that are separately.

Is Leqvio covered by Medicare Part D?

As you would receive Leqvio (inclisiran) in a doctors office, the medication should be covered by Part B.

LEQVIO (inclisiran) Provider Claim Reimbursement Request 2026

Here's how it works

How to use or fill out LEQVIO (inclisiran) Provider Claim Reimbursement Request

Complete this form in 5 minutes or less

Got questions?

How do I get help paying for LEQVIO?

What is a covered diagnosis for LEQVIO?

How to get Leqvio covered?

What is the FDA approved diagnosis for Leqvio?

What is the ICD code for Leqvio?

Security and compliance

Complete this form in 5 minutes or less

People also ask

Does LEQVIO require prior authorization?

How to bill for LEQVIO?

Is Leqvio covered by Medicare Part D?

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