ORBACTIV Support Programs
Page 1 of 2 SERVICE(S) REQUESTED Check all that apply: Insurance Verification Prior Authorization Assistance Copay Savings Program Patient Assistance Program (PAP) (NOTE: For Copay Savings Program and Patient Assistance Program, complete and sign page 2)
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HIGHLIGHTS OF PRESCRIBING INFORMATION …
www.orbactiv.com2 FULL PRESCRIBING INFORMATION 1 INDICATIONS AND USAGE 1.1 Acute Bacterial Skin and Skin Structure Infections ORBACTIV® (oritavancin) for injection is indicated for the treatment of adult patients with
ICD-10 diagnostic codes consistent with ORBACTIV ...
www.orbactiv.comICD-10-CM Diagnosis Codes Diagnosis Staphylococcus A49.01 Methicillin susceptible staphylococcus aureus, unspecified site A49.02 Methicillin resistant …
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HIGHLIGHTS OF PRESCRIBING INFORMATION WARNINGS …
www.orbactiv.com2 FULL PRESCRIBING INFORMATION 1 INDICATIONS AND USAGE 1.1 Acute Bacterial Skin and Skin Structure Infections ORBACTIV® (oritavancin) for injection is indicated for the treatment of adult patients with acute bacterial skin and skin structure infections (ABSSSI) caused by susceptible isolates of the