NUPLAZIDconnect
Enrollment
Cost
Coverage
Getting NUPLAZID
Diagnostic Codes

Get started with the enrollment process

Actor Portrayals

A few answers to get started

If you need to get a prescription for your patient, fill out the treatment form.

If you need long-term care access services, fill out the long-term care service request form.

You can complete the form through the form fields below (recommended), or download the PDF version of the long-term care form and fax it to 1-844-737-2224.

Complete the long-term care service request form in just 5 steps:

Step 1:
Resident Information

All information required unless marked optional

This field is required.

Gender (optional)

Female Male

Preferred Contact

Patient Caregiver

This field is required.

Preferred Contact Time (optional)

Morning Afternoon Evening

This field is required.

Resident Signature/Legal Guardian HIPAA Authorization (optional)

By signing this authorization, I authorize my health plans, physicians, and pharmacy providers to disclose my Protected Health Information (“PHI”), including, but not limited to, information relating to my medical condition, treatment, care management, and health insurance, as well as information provided on this form and any prescription to ACADIA Pharmaceuticals Inc. (“ACADIA”) and its representatives or agents, including ACADIAʼs NUPLAZIDconnect Support Center operated by The Lash Group, Inc. on behalf of ACADIA

I have read and agree to HIPAA authorization.

CLEAR

In order to continue, you must correct the errors above.

Step 2:
Insurance Information

Complete the long-term care service request form in just 5 steps:

<<previous

Step 2:
Insurance Information

All information required unless marked optional

Insurance Status

Resident has insurance.

Resident does not have insurance.

This field is required.

Optional Insurance Information

In order to continue, you must correct the errors above.

Step 3:
Facility Address

Complete the long-term care service request form in just 5 steps:

<<previous

Step 3:
Facility Address

All information required unless marked optional

Patient Resides:

In Assisted Living

In a Skilled Nursing Facility/Nursing Home

This field is required.

This format is invalid.

Check this box if your resident is currently covered under Medicare Part A.

This field is required.

This format is invalid.

In order to continue, you must correct the errors above.

Step 4: Services Needed/
Diagnosis Information

Complete the long-term care service request form in just 5 steps:

<<previous

Step 4:
Services Needed/Diagnosis Information

All information required unless marked optional

Please select the NUPLAZIDconnect services needed (check all that apply):

Perform a benefits investigation on behalf of your resident

Support you in the prior authorization/appeals process, if required by your resident’s insurance company

Provide information about financial assistance programs, if your resident is eligible

This selection is required.

Please confirm diagnosis

Hallucinations and delusions associated with Parkinson’s disease (PD) psychosis (includes G20 Parkinson’s disease)

This selection is required.

Other diagnosis

Coding must be to the highest level of specificity, and all coding decisions are ultimately the responsibility of each prescribing healthcare professional.

Prescriber Authorization

This field is required.

Prescriber Authorization: I attest that I have obtained the HIPAA authorization, and any other written permission that may be required under applicable law, of my patient (or the patientʼs legal representative) for the release of my patientʼs Protected Health Information (“PHI”) to Lash or its representatives or agents (the “Program”) as may be

You must read this completely.

CLEAR

A signature is required.

This field is required.

This format is invalid.

In order to continue, you must correct the errors above.

Step 5: Authorization &
Submission

Complete the long-term care service request form in just 5 steps:

<<previous

Step 5:
Authorization & Submission (optional)

All the information below is optional. If you choose not to complete it, scroll to the bottom and hit "Submit Long Term Care Service Request Form"

AUTHORIZATION TO DISCLOSE INFORMATION TO INDIVIDUALS INVOLVED IN MY CARE (optional)

I further authorize ACADIA Pharmaceuticals Inc. to discuss the coordination of my care with the following family member(s) and/or caregiver(s):

CLEAR

Submit long-term care service request form

You have successfully submitted the long-term care service request form for x

Download a copy to save for your records.

Download PDF

Return to NUPLAZIDconnect

You can complete the form through the form fields below (recommended), or download the PDF version of the treatment form and fax it to 1-844-737-2224.

Complete the treatment form in just 5 steps:

Step 1:
Patient Information

All information required unless marked optional

This field is required.

This selection is required.

This field is required.

This format is invalid.

This field is required.

This format is invalid.

Gender (optional)

Female Male

Preferred Contact

Patient Caregiver

This field is required.

This format is invalid.

This field is required.

This format is invalid.

This field is required.

Patient Resides:

At Home

In Assisted Living

In a Skilled Nursing Facility/Nursing Home

This field is required.

This format is invalid.

Patient HIPAA
Signature (optional)

I have read and agree to HIPAA authorization.

CLEAR

In order to continue, you must correct the errors above.

Step 2:
Insurance Information

<<previous

Step 2:
Insurance Information

All information required unless marked optional

Patient has insurance.

Patient does not have insurance.

This field is required.

This format is invalid.

This field is required.

Optional Insurance Information

In order to continue, you must correct the errors above.

Step 3:
Prescriber Information

Complete the treatment form in just 5 steps:

<<previous

Step 3:
Prescriber Information

All information required unless marked optional

This field is required.

This format is invalid.

This field is required.

This selection is required.

This field is required.

This format is invalid.

This field is required.

This format is invalid.

You must read this completely.

CLEAR

A signature is required.

This field is required.

This format is invalid.

In order to continue, you must correct the errors above.

Step 4:
Diagnosis & Prescription

Complete the treatment form in just 5 steps:

<<previous

Step 4:
Diagnosis & Prescription

All information required unless marked optional

Please confirm diagnosis

Hallucinations and delusions associated with Parkinson’s disease (PD) psychosis (includes G20 Parkinson’s disease)

This selection is required.

Other diagnosis

Coding must be to the highest level of specificity, and all coding decisions are ultimately the responsibility of each prescribing healthcare professional.

NUPLAZID^® (pimavanserin) ONGOING PRESCRIPTION

Sig. Take One 34 mg Capsule Orally, Once Daily^1†

This selection is required.

Other^*

This selection is required.

Avoid the use of NUPLAZID with drugs that also increase the QT interval and in patients with risk factors for prolonged QT interval.

*The recommended dose of NUPLAZID when coadministered with strong CYP3A4 inhibitors (eg, ketoconazole) is 10 mg, taken orally as one tablet once daily.

Avoid concomitant use of strong or moderate CYP3A4 inducers with NUPLAZID.¹

^†See Full Prescribing Information, including Boxed WARNING, for dosing recommendations (including drug/drug interactions).

Dispense: 30-day Supply

This selection is required.

Number of refills

This selection is required.

Number of Days to be Dispensed*

This selection is required.

Substitution Permitted (optional)

CLEAR

Dispense as Written

CLEAR

A signature is required.

This field is required.

This format is invalid.

FREE 14-DAY SUPPLY OF NUPLAZID (OPTIONAL)
(only for patients diagnosed with hallucinations and delusions associated with PD psychosis)

Sig. Take One 34 mg Capsule Orally, Once Daily (optional)

Dispense: 14-day Supply (optional)

Other (optional)

Number of Days to be Dispensed

Note: Free 14-day supply of NUPLAZID to be dispensed by TheraCom Pharmacy. NUPLAZID will only be dispensed and delivered to facilities that accept free product.

NUPLAZIDconnect^™ may send a second free 14-day supply if extra time is needed. (optional)

CLEAR

In order to continue, you must correct the errors above.

Step 5: Authorization &
Submission (optional)

Complete the treatment form in just 5 steps:

<<previous

Step 5:
Authorization & Submission (optional)

All the information below is optional. If you choose not to complete it, scroll to the bottom and hit "Submit Treatment Form"

AUTHORIZATION TO DISCLOSE INFORMATION TO INDIVIDUALS INVOLVED IN MY CARE (optional)

I further authorize ACADIA Pharmaceuticals Inc., to discuss the coordination of my care with the following family member(s) and/or caregiver(s):

CLEAR

Submit treatment form

You have successfully submitted the treatment form for x

Download a copy to save for your records.

Download PDF

Return to NUPLAZIDconnect

Get started with the enrollment process

A few answers to get started

Complete the long-term care service request form in just 5 steps:

Step 1:
Resident Information

Resident Signature/Legal Guardian HIPAA Authorization (optional)

Complete the long-term care service request form in just 5 steps:

Step 2:
Insurance Information

Complete the long-term care service request form in just 5 steps:

Step 3:
Facility Address

Complete the long-term care service request form in just 5 steps:

Step 4:
Services Needed/Diagnosis Information

Complete the long-term care service request form in just 5 steps:

Step 5:
Authorization & Submission (optional)

Complete the treatment form in just 5 steps:

Step 1:
Patient Information

Patient HIPAA
Signature (optional)

Step 2:
Insurance Information

Complete the treatment form in just 5 steps:

Step 3:
Prescriber Information

Complete the treatment form in just 5 steps:

Step 4:
Diagnosis & Prescription

Substitution Permitted (optional)

Complete the treatment form in just 5 steps:

Step 5:
Authorization & Submission (optional)

Important Safety Information and Indication for NUPLAZID (pimavanserin)

WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS

Indication

Dosage and Administration

Get started with the enrollment process

A few answers to get started

Step 1:Resident Information

Resident Signature/Legal Guardian HIPAA Authorization (optional)

Step 2:Insurance Information

Step 3:Facility Address

Step 4:Services Needed/Diagnosis Information

Step 5:Authorization & Submission (optional)

Step 1:Patient Information

Patient HIPAASignature (optional)

Step 2:Insurance Information

Step 3:Prescriber Information

Step 4:Diagnosis & Prescription

Substitution Permitted (optional)

Step 5:Authorization & Submission (optional)

Important Safety Information and Indication for NUPLAZID (pimavanserin)

WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS

Indication

Dosage and Administration

Step 1:
Resident Information

Step 2:
Insurance Information

Step 3:
Facility Address

Step 4:
Services Needed/Diagnosis Information

Step 5:
Authorization & Submission (optional)

Step 1:
Patient Information

Patient HIPAA
Signature (optional)

Step 2:
Insurance Information

Step 3:
Prescriber Information

Step 4:
Diagnosis & Prescription

Step 5:
Authorization & Submission (optional)