Alnylam Assist™ Online Start Form

Help your patient get started on OXLUMO® (lumasiran) by filling out the electronic Start Form together.
The purpose of this form is to permit Alnylam Assist™ participants to receive additional information and support (“Patient Support”) from Alnylam Pharmaceuticals, Inc., its affiliates, representatives, agents, and contractors (“Alnylam”). Alnylam Assist™ provides Patient Support to eligible patients who have been prescribed an Alnylam medicine. This includes: (1) providing reimbursement and financial support to eligible patients (such as investigating your insurance coverage, confirming out-of-pocket costs, and reviewing eligibility for financial assistance); (2) working with you and your provider to fill their prescription; and (3) providing you with disease and medication-related educational resources and communications. Your authorization in this form will relate to information and support with respect to any Alnylam medicine you have been prescribed or may need to be prescribed in the future.
PLEASE NOTE: Patients and healthcare providers should be together when filling out the Start Form. Consent via electronic signature is mandatory for submission of the form. Forms must be submitted once started, as progress will not be saved. If you are unable to complete the electronic Start Form with your patient, you can begin filling out the form and email it to your patient via DocuSign.
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  • Patient Information
  • Insurance Information
  • Patient Authorization
  • Prescriber Information
  • OXLUMO Prescription
  • Confirm & Submit
Patient Information
* Indicates required field
Caregiver Information (Optional)
Additional Patient Information
*Language Translation?
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IMPORTANT SAFETY INFORMATION

Adverse Reactions
The most common (≥20%) adverse reaction reported in patients treated with OXLUMO was injection site reaction. Injection site reactions included erythema, swelling, pain, hematoma, pruritus, and discoloration.

Pregnancy and Lactation
No data are available on the use of OXLUMO in pregnant women. No data are available on the presence of OXLUMO in human milk or its effects on breastfed infants or milk production. Consider the developmental and health benefits of breastfeeding along with the mother’s clinical need for OXLUMO and any potential adverse effects on the breastfed child from OXLUMO or the underlying maternal condition.

INDICATION

OXLUMO® (lumasiran) is indicated for the treatment of primary hyperoxaluria type 1 (PH1) to lower urinary and plasma oxalate levels in children and adults.

For additional information about OXLUMO, please see the full Prescribing Information.