Heron Connect® | Downloadable Resources for SUSTOL® (granisetron) extended-release injection

Reimbursement resources

Sample CMS-1450 (UB-04) Claim Form

Sample form with annotations and instructions.

Sample CMS-1500 Form

Sample form with annotations and instructions.

Sample Letter of Medical Appeal

A letter with a customizable template for you to use if a health plan denies your patient access to SUSTOL.

Sample Letter of Medical Necessity

A customizable letter your practice can use to provide health plans with a brief medical rationale for the use of SUSTOL.

Product and program information

Distribution Reference Guide

For explaining how and where to order SUSTOL^®.

Coding Reference Guide

Listing of Diagnostic, NDC, HCPCS, JW Modifier, CPT, and Revenue Codes for SUSTOL.

SUSTOL product-specific J-Code is J1627.

Heron Connect Reimbursement Support Reference Guide

Reference guide describing the Heron Connect Programs and Services.

Heron Commitment Program^® Flashcard

Highlights the coverage denial support provided to your practice through the Heron Commitment Program.

Product Replacement Policy Guide

Highlights the product replacement policy offered to healthcare providers or direct purchasing customers through Heron Connect.

Forms

Insurance Verification and Program Enrollment Form

One single form used to verify benefits and enroll patients in Heron Connect Programs.

Practice Copay Assistance Program Enrollment Form

A one-time form your practice must complete in order to participate in the simplified Heron Connect Copay Assistance Program registration process.

Patient Copay Assistance Program Registration Form

A form used to enroll individual patients solely into the Heron Connect Copay Assistance Program. The one-time Practice Copay Assistance Program Enrollment Form must also be completed.

Heron Commitment Program^® Enrollment Form

A form your practice must complete in order to be eligible for the Heron Commitment Program.

Clinical materials and patient resource

Instructions for Use (IFU)

A document with information about the preparation and administration of SUSTOL^®.

Administration Tear Sheet

Illustrated overview and helpful hints to administer SUSTOL.

Patient Education Flashcard

A flashcard that provides important information about what your patient can expect when receiving SUSTOL.

Click to view English or Spanish versions.

Spanish

IMPORTANT SAFETY INFORMATION

Contraindications

SUSTOL is contraindicated in patients with hypersensitivity to granisetron, any of the components of SUSTOL, or any other 5-HT₃ receptor antagonist.

Warnings and Precautions

Injection site reactions (ISRs), including infection, bleeding, pain and tenderness, nodules, swelling, and induration, have occurred with SUSTOL. Monitor for ISRs following SUSTOL injection. Inform patients that some ISRs may occur 2 weeks or more after SUSTOL administration. In patients receiving antiplatelet agents or anticoagulants, consider the increased risk of bruising or severe hematoma prior to the use of SUSTOL.

Monitor for constipation and decreased bowel activity and consider optimizing patients’ current bowel regimens used for managing preexisting constipation. Instruct patients to seek immediate medical care if signs and symptoms of ileus occur.

Hypersensitivity reactions have been reported and may occur up to 7 days or longer following SUSTOL administration and may have an extended course. If a reaction occurs, administer appropriate treatment and monitor until signs and symptoms resolve.

Serotonin syndrome has been reported with 5-HT₃ receptor antagonists alone but particularly with concomitant use of serotonergic drugs.

Use in Specific Populations

Avoid SUSTOL in patients with severe renal impairment. In patients with moderate renal impairment, administer SUSTOL not more frequently than once every 14 days.

Adverse Reactions

Most common adverse reactions (≥3%) are injection site reactions, constipation, fatigue, headache, diarrhea, abdominal pain, insomnia, dyspepsia, dizziness, asthenia, and gastroesophageal reflux.

Report side effects to the FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. Report side effects to Heron at 1-844-437-6611.

Heron Connect® Downloadable Resources

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Reimbursement resources

Sample CMS-1450 (UB-04) Claim Form

View form

Sample CMS-1500 Form

View form

Sample Letter of Medical Appeal

View letter

Sample Letter of Medical Necessity

View letter

Product and program information

Distribution Reference Guide

View guide

Coding Reference Guide

View guide

Heron Connect Reimbursement Support Reference Guide

View guide

Heron Commitment Program® Flashcard

View flashcard

Product Replacement Policy Guide

View guide

Forms

Insurance Verification and Program Enrollment Form

View form

Practice Copay Assistance Program Enrollment Form

View form

Patient Copay Assistance Program Registration Form

View form

Heron Commitment Program® Enrollment Form

View form

Clinical materials and patient resource

Instructions for Use (IFU)

View IFU

Administration Tear Sheet

View tear sheet

Patient Education Flashcard

English

Spanish

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INDICATION

IMPORTANT SAFETY INFORMATION

Contraindications

Warnings and Precautions

Use in Specific Populations

Adverse Reactions

Heron Connect^® Downloadable Resources

Heron Commitment Program^® Flashcard

Heron Commitment Program^® Enrollment Form