SpringWorks CareConnections™ Resources & Forms
Additional Resources to Support Your Patients
We provide information you need, when you need it, so you can support your patients on their treatment journey with GOMEKLI™ (mirdametinib).

Downloadable Resources
Explore our resources below and visit GOMEKLI.com for more about GOMEKLI.
Enrollment Form

SpringWorks CareConnections™ Enrollment Form
Complete this form to get your patients started with SpringWorks CareConnections today.
Download English Version Download Spanish VersionSpringWorks CareConnections Brochures

SpringWorks CareConnections HCP Brochure
Discover the resources available for you and your office staff through SpringWorks CareConnections to help facilitate patient access to GOMEKLI.
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SpringWorks CareConnections Patient Brochure
Share this helpful overview of SpringWorks CareConnections with your patients.
Download English Version Download Spanish VersionSample Letters and Checklists

Sample Letter of Medical Necessity or Medical Exception for GOMEKLI
Refer to this example when a letter of medical necessity or medical exception is appropriate.
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Sample Letter of Appeal for GOMEKLI
Refer to this example when a letter of appeal of a PA denial is appropriate.
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Alternative Funding Program (AFP) Sample Letter
Refer to this example when contacting a patient’s insurance provider to request coverage for GOMEKLI where an AFP is involved.
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GOMEKLI Prior Authorization (PA) Tips and Checklist
This checklist can serve as a guide through the PA process.
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GOMEKLI Appeals Tips and Checklist
This checklist can serve as a guide through the appeals process.
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Peer-to-Peer Checklist
This resource provides a checklist and relevant tips to help you prepare for and engage in a peer-to-peer discussion.
DownloadAdditional Resources

GOMEKLI Treatment Access Guide
This guide outlines the process for prescribing GOMEKLI and the support services offered by SpringWorks CareConnections that may help address access barriers.
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GOMEKLI Coverage Tool Kit
This guide provides information and resources to help HCPs and office staff navigate potential access challenges when prescribing GOMEKLI.
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GOMEKLI Product Fact Sheet and Ordering Guide
Find out about GOMEKLI and how to prescribe through our limited network of Specialty Pharmacies or order directly through our Specialty Distributor partners.*
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Evidence Compendium
This resource provides a library of articles that support why GOMEKLI may be medically necessary and should be covered by a patient’s health plan.
Download
ICD-10-CM Code Flashcard
Discover location-specific ICD-10-CM codes.
Download
Navigating Health Insurance Brochure
Share with patients to help them learn about some of the different types of health insurance as well as select terms related to obtaining coverage.

Navigating Health Insurance as a Young Adult Brochure
Share with young adult patients to help them learn about health insurance and transitioning onto their own health insurance plan.

GOMEKLI Electronic Health Record (EHR) Flashcard
Learn more about how to add GOMEKLI to your EHR system.
* | May not be available for all practices or organizations. |
Stay Connected About GOMEKLI
Click here to receive information, updates, and resources for GOMEKLI.
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