Prescription and Service Request Form

Acquiring CINQAIR® Administering CINQAIR® Supporting Patients FAQs Resources

Supporting Patients

  • Teva Support Solutions® offers access and affordability support for patients prescribed CINQAIR® (reslizumab) Injection.
  • A Case Administrator is ready to help with benefits verification, prior authorization support, and information about financial assistance programs for eligible patients. Nurses are available by phone with information and answers to patients’ questions about treatment with CINQAIR®.
  • A Clinical Nurse Educator may be able to help with support and education. Contact Teva Support Solutions® to find out more.

Access Support


Affordability Support

Simplifying Benefits Investigation and Verification

  • Teva Support Solutions® offers information and resources to help patients get access to treatment with CINQAIR® (reslizumab) Injection.
  • With a completed Prescription and Service Request Form, a Case Administrator will investigate and verify benefits.
  • A Summary of Benefits will be faxed to the prescriber and will include important information about the patient’s insurance coverage for treatment with CINQAIR®.
  • Teva Support Solutions® offers additional support for prior authorization (PA) and exceptions and appeals processes.

Be sure to select all the appropriate
services on the Prescription and Service Request Form.


To assist you in completing the form, download “A Guide to the Prescription and Service Request Form”.


Coverage Assistance

Teva Support Solutions® can provide help with a patient’s health insurance coverage approval processes for treatment with CINQAIR®.

Support for the Prior Authorization Process

  • The Summary of Benefits provided by Teva Support Solutions® will include important information about the patient’s health insurance coverage for CINQAIR®.
  • If a prior authorization (PA) is needed, Teva Support Solutions® may include the health plan’s PA form and submissions instructions with the Summary of Benefits.
  • A PA form may also be available on the health plan’s website.

Letter of Medical Necessity

If the patient’s health plan requires a Letter of Medical Necessity, Teva Support Solutions® provides support with a Letter of Medical Necessity template.

Letter of Appeal

If the patient’s health plan denies coverage for CINQAIR®, Teva Support Solutions® provides support with a Letter of Appeal template.

Affordability Support