In it right
from the start

Seagen Secure® works with your practice and your patients to get them enrolled* and started on TUKYSA® (tucatinib) tablets therapy quickly. Once a patient is enrolled, Seagen Secure® will help to ensure the patient is covered by their insurance.

*Seagen does not guarantee that enrollment will result in patient assistance, coverage, and/or reimbursement.

*Seagen does not guarantee that enrollment will result in patient assistance, coverage, and/or reimbursement.

How to enroll your patients for
TUKYSA® (tucatinib) tablets therapy

In-office with your patient

Sit down with your patient and fill out our online enrollment form. Make sure your patient has their personal, insurance, and financial information available.

Click to complete the online enrollment form
Fax icon

FAX 855-557-2480

Download and complete the Healthcare Provider Request Form and Patient Authorization Form.

Phone icon

Phone 855-473-2873

Contact Seagen Secure® to enroll over the phone, Monday-Friday, 8 am-8 pm ET.

Case Manager

Once enrolled, your patient will be assigned a dedicated Case Manager who can assist with any coverage or financial issues:

Benefits investigation icon

Benefits investigation

The Case Manager will help determine coverage, evaluate prior authorization requirements or other restrictions, and determine the patient’s financial responsibility

Commercial out-of-pocket assistance program icon

Commercial out-of-pocket assistance program 

The Case Manager can offer your patient enrollment in this program, designed to lower out-of-pocket costs for each prescription

Appeals assistance icon

Appeal assistance

If a patient’s insurer denies a prior authorization request and you want to appeal, the Case Manager can identify the appropriate steps

Uninsured and underinsured patient assistance icon

Uninsured and underinsured patient assistance

The Case Manager can provide eligible patients with TUKYSA therapy, free of charge

Patients must meet eligibility requirements.

Oncology Nurse Advocate

Your patients may face many other treatment challenges. That is why Seagen Secure® provides each patient with the support of an Oncology Nurse Advocate. They will assist with:

Emotional Support

Connecting patients to social workers, counseling services, or online communities

Logistical Support

Assisting with transportation and lodging for treatment and help with other day-to-day tasks

Informational Support

Offering educational resources about the patient’s disease and treatment, while connecting caregivers to organizations and resources that can help

Compliance and Adherence Support

Helping patients adhere to the drug regimen

Additional Assistance Information

Referring patients to independent, outside organizations for additional services, if needed

Information provided by the Oncology Nurse Advocate is not intended to be a substitute for advice from the patient’s healthcare professional. Patients are always encouraged to speak with their healthcare professionals about all medication issues or concerns. Seagen does not guarantee that enrollment will result in coverage or reimbursement.

Quick Start Program

Get patients on TUKYSA without delay

Your patients who are already enrolled in Seagen Secure® may apply to the Quick Start Program if their coverage determination is delayed.

  • Once coverage delay is determined, Seagen Secure® will initiate Quick Start for eligible patients
  • During the coverage delay, a 15-day supply of TUKYSA may be provided free of charge
Call a Case Manager to sign up for Quick Start

Enrollment Steps

  1. Complete this form with your patient
    • In-office
    • Remotely
  2. Submit to Seagen Secure®
    • A Case Manager will reach out within 1-2 business days

Make sure you have the following information to complete the enrollment form:

  • Your practice information, including:
    • Address and contact details
    • Tax ID Number
    • National Provider Identifier (NPI)
  • Details regarding your patient's clinical diagnosis and treatment
  • Your patient's personal, financial, and contact details
  • Your patient's insurance card and/or insurance information
Let’s get started

Enrollment Form

Physician Information

Clinical Information

Insurance Information

Patient Information

Authorization

Declaration

Declaration

Physician Information

Clinical Information

Insurance Information

Patient Information

Authorization

Declaration

Declaration

All fields required unless otherwise indicated.

All fields required unless otherwise indicated.

Gender

Does patient have HER2+ mutation?
Does patient have brain metastases?
Prescription Information
30-day supply
Current or Preferred Pharmacy

Selection will be honored if permitted by patient's insurance coverage.

15-day supply / No Refills

All fields required unless otherwise indicated.

Please select one:

Speed things up and avoid mistakes! Upload a photo of your insurance card:
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Secondary / Pharmacy Coverage
Does patient’s employer offer health insurance?
Does patient’s spouse have an employer who offers health insurance?
Has patient attempted to enroll in a health insurance exchange (HIE) plan?
Has patient attempted to apply for Medicaid in their state?

All fields required unless otherwise indicated.

Additional patient information for [Firstname Lastname].

This section is only required for patients enrolling in the Seagen Secure® Patient Assistance Program for free medicine. If all criteria are met, you may be eligible to receive your medication free of charge.

* Seagen Secure® reserves the right to request documentation proving income.
By opting in to the Oncology Nurse Advocate Program, you are selecting to be contacted by a registered oncology nurse. Opting out of this program will not impact Seagen Secure’s ability to help you access treatment.

All fields required unless otherwise indicated.

Patient Authorization

Seagen Secure® is a program provided to you, free of charge, from Seagen by its authorized agents. Seagen Secure® is here to help you navigate access to Seagen’s products. Seagen Secure® may:

  1. assist me with my enrollment in Seagen Secure® and assess my eligibility for participation in the Commercial Out-of-Pocket Assistance Program(s) and, if found eligible, enroll me;
  2. contact me by phone, mail, or email to request further information;
  3. provide me with educational and other materials, information, and support related to Seagen Secure®;
  4. verify, investigate, and assist me with determining coverage for my prescribed medication from my health insurance plan;
  5. assess my eligibility for participation in the patient assistance program, if necessary;
  6. refer me to other independent programs or alternative sources that may be available to provide assistance to me as allowed under the law, if necessary;
  7. for Seagen’s internal business purposes, including quality control and support enhancing survey.

I consent to Seagen Secure® contacting me, my physician(s), and insurance provider(s) for the purposes described above.

In order to assist you in the manner described above, Seagen Secure® must have access to protected health information, or “PHI.” This means information including, but not limited to, my name, address, contact number, medical condition, and health insurance provider may be disclosed. I authorize my doctors, pharmacies, and other healthcare providers, as well as my health insurance plan, to disclose to Seagen (“Company”), and its third-party suppliers, vendors, and other service providers supporting Seagen Secure® (collectively, the “Service Providers”), my protected health information to help me get access to my prescribed medication. I also authorize Seagen Secure® to access my credit information for the purposes of verifying my income as part of the eligibility screening for the Patient Assistance Program (PAP). I understand that completing this form does not guarantee that I will qualify for and be enrolled into the Seagen PAP. I understand that I can refuse to sign this Authorization which will have no impact on my treatment, payment for treatment, or insurance coverage but Seagen Secure® will not be able to assist me in accessing my medication. This Authorization will last for two years from the date on which I agree to this Authorization (or such shorter period as applicable state law may require).

I have been made aware that the privacy statement of Seagen, available at www.seagen.com/privacy, describes its privacy practices, including how I may exercise certain rights with respect to my data. I understand that I may revoke this Authorization at any time by providing written notice to Seagen Secure® at 2730 S. Edmonds Lane, Suite 300, Lewisville, TX 75067. Cancellation of this Authorization will be valid when received by the administrators of Seagen Secure®.

By signing this form, as described herein, I agree to allow Seagen and its agents to use my personal information. I understand that I am entitled to receive a copy of this authorization after I have provided my signature.

Signature:

All fields required unless otherwise indicated.

HCP Declaration

Seagen Secure® offers a comprehensive reimbursement and access program for patients. By providing the Patient Information (including Health Insurance Information), you represent that you have the patient’s consent to provide his/her information for purposes of verifying benefits and/or PAP consideration for the Seagen’s product as indicated in the title of this form above; and that you have written patient authorization(s) as required by applicable state or federal law to release the Patient Information on this form.

The healthcare provider and patient remain fully responsible for all claims made to private insurers or government programs, including the accuracy of all information submitted. All claims for Seagen products should be made in accordance with legal and contractual requirements. Many factors influence reimbursement, and the policies and practices of private and public payers may change without notice. Seagen reserves the right to modify or discontinue the program, without notice, at any time.

Upon reasonable notice in writing, and not more than once per coverage year, Seagen Inc. shall have the right to audit and examine all documents, correspondence and records related to enrolled patients and product shipments. Upon request, a representative duly authorized by Seagen Inc. may contact you by phone or email with an audit request for all or some of your enrolled patients. Complete responses to an audit are required within 30 days of said request. Non-compliance may lead to the possibility of program discontinuation for all or some of your patients.

Seagen Inc. and Seagen Secure® will utilize this patient information solely for the purposes of a benefits investigation and patient assistance assessment. The program will not sell, rent, or otherwise distribute any patient information outside of Seagen Inc. or its agents.

I have been made aware that the privacy statement of Seagen, available at www.seagen.com/privacy, describes its privacy practices, including how I may exercise certain rights with respect to my data.

MD or Healthcare Provider Contact Signature

Success! The enrollment has been submitted!

Here is the physician information we’ve gathered so far. We can save it for you so your next enrollment will be quicker.
Would you like us to save this information?
Physician Name
Dr. Elenor Arroway
Group or Hospital
Dr. Elenor Arroway
Tax ID Number
Dr. Elenor Arroway
NPI
Dr. Elenor Arroway
Address
123 South Main St Middleburg, NY 12345
Office Contact Name
Dr. Elenor Arroway
Office Contact Phone Number
Dr. Elenor Arroway
Fax Number
Dr. Elenor Arroway
Email Address
Dr. Elenor Arroway

Resources and Forms

Seagen Secure® provides materials to help your patients get started on therapy

All materials listed are readily available to download:

Enrollment Forms

Combined Healthcare Provider Request and Patient Authorization Forms

Download English PDF Download Spanish PDF

Healthcare Provider Request Form

Download English PDF Download Spanish PDF

Patient Authorization Form

Download English PDF Download Spanish PDF

Enrollment Form Instructions

Download PDF

Reimbursement and Other Resources

Appeals Request Guide

Download PDF

ICD-10 Guide

Download PDF

Prior Authorization Guide

Download PDF

TUKYSA® (tucatinib) Prescribing Information

Download PDF

Quick Guides

Seagen Secure® Flashcard

Download PDF