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How Do Providers Enroll?
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Providers interested in participating in this project should first review the criteria for participation and then fill out and submit the items listed below.

Online Application

The online provider application will need to be submitted along with your medical protocol or indication that you will use FADAA's medical protocol in the application. FADAA's sample medical protocol can be found on our website at the following URL:

Sample Medical Protocol

After the application is completed, it can be submitted electronically and will be reviewed by FADAA. When the application is approved, the provider will receive a Memorandum of Agreement (MOA) with FADAA.

Sample MOA

The provider's chief executive officer (CEO) or equivalent must sign the agreement and return it to FADAA for signature by the CEO of FADAA. The agreement is not final until signed by both parties.  The MOA covers one state fiscal year; a renewal MOA must be signed and returned to FADAA prior to July 1st of each year.

Providers will also need to establish a business credit account with Besse Medical, the specialty pharmacy that is providing the drug for agencies enrolled in this project. 

Besse Business Application

The application may be submitted electronically or completed and faxed to Besse at (1-888-375-0030). You will be notified within 48 hours and will receive a Besse account number. You will also need to complete an Uninsured Provider Certification form and submit it to Alkermes. To receive this form please contact:

Jeff Armstrong
Alkermes, Inc.

On the provider certification form, please be sure to include your Besse account number and be sure the DEA number on the certification form matches the DEA number on the Besse account. The form should be faxed to 1-952-513-4826.

After the agreement is final and your account is established you will be able to enroll participants in the program.