NeedyMeds

Transcription

1 NeedyMeds Find help with the cost of medicine Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need. REMEMBER - Send your completed application to address on the form, NOT to NeedyMeds. Did you know that NeedyMeds has thousands of other free resources? Here s a look at more ways we can help you save money on medicine and healthcare costs. Each one can be found under the Patient Savings tab on our website: Diagnosis-Based Assistance NeedyMeds lists thousands of assistance programs for almost any health condition. If you are going through chemo treatment for cancer, there are programs that can help with wig costs and scalp-cooling products. We also list resources for free diabetes testing supplies, caregiver lodging support, and much more. Free, Low Cost, and Sliding Scale Clinics This popular collection contains information on 16,000+ free, low cost, and sliding scale medical and dental clinics across the U.S. It s a great resource if you need affordable medical treatment and don t know where to go. Coupons, Rebates & More You can use the NeedyMeds website to find nearly 2,000 cost-saving opportunities for both prescription and over-the-counter drugs and medical supplies. Medical Transportation Need help getting to the doctor s office or medical facility? You may be eligible for financial assistance if you meet certain requirements. Finally, I want to tell you about the NeedyMeds Drug Discount Card. Thousands of people use this free, anonymous, and easy-to-use tool to get the best price on their medications. To date, our drug discount card has saved patients over $244,000,000. Check out the next page to learn more. Feel free to call our toll-free helpline if you have any questions. You can reach us at Monday-Friday, 9am-5pm Eastern Time. Thanks for using NeedyMeds! Please let us know if we can do anything else to help you afford the costs of your healthcare. Rich Sagall, MD Richard J. Sagall, MD President, NeedyMeds NeedyMeds.org P.O. Box 219 Gloucester, MA Phone: info@needymeds.org

2 Clip the card and save NeedyMeds NeedyMeds.org DRUG DISCOUNT CARD BIN: RX PCN: NMEDS RX GRP: PDFPDF ID: NMNA This is a drug discount program, not an insurance plan. NeedyMeds Drug Discount Card Patient: Simply present this card to a participating pharmacy to receive a discount on your prescription. Patients who have Medicare, including Part D, Medicaid or any state or federal prescription insurance can only use this card if they choose not to use their government-sponsored drug plan for their purchase. The card is not valid in combination with those programs. For questions concerning the card, call or visit Pharmacist: Card must be presented to receive program benefits. Clear system of prior cardholder information associated with this universal cardholder ID. For processing questions, call Argus Health Systems at Save up to 80% Use at over 65,000 pharmacies nationwide including all major chains Share the card with friends and family Use the card as often as needed Free, no fees or registration Never expires What if I have insurance? Anyone can use the card, but it can t be combined with insurance. You can use the card instead of insurance if: A drug isn t covered by your insurance Your insurance has no drug coverage You have a high drug deductible You have met a low medicine cap The card offers a better price than your copay You are in the Medicare Part D donut hole What drugs are covered? The card is good for prescription drugs, over-the-counter medicines and medical supplies if written on a prescription blank, and pet prescription medicines purchased at a pharmacy. You ll save on most, but not all, prescriptions. To obtain a plastic drug discount card, send a self-addressed stamped envelope to: NeedyMeds-PAP PO Box 219 Gloucester, MA The card is not valid in combination with other insurance plans, including Medicare, Medicaid or any state or federal prescription insurance. The card can be used only if you decide not to use your government-sponsored drug plan for your purchases.

3 INSTRUCTIONS FOR ENROLLMENT Are you eligible? The Genentech Patient Foundation gives free medicine to people who are: Uninsured No insurance and a household income of less than $150,000 each year OR Insured, but Lack Coverage Insurance that does not cover their Genentech medicine and a household income of less than $150,000 each year* OR Insured, but Medicine Is Unaffordable Insurance coverage for their Genentech medicine, but have trouble paying for their medicine even after using other assistance options, and a yearly household income of less than: $75,000 for a household of 1 person $100,000 for a household of 2 people $125,000 for a household of 3 people $150,000 for a household of 4 people More than 4 people in your household? Add $25,000 for each additional person. There is no maximum number of people that you may add. If none of the situations above apply or you are unsure of your insurance coverage, Genentech Access Solutions can help. Genentech Access Solutions is a program from Genentech and is committed to helping you understand your insurance coverage and options that might be able to help you pay for your Genentech medicine. Call (866) or visit Genentech-Access.com for more information. How to apply 1. Patient fills out and signs page Prescriber fills out and signs page Completed application is faxed to (833) What to expect after applying? Once an eligibility determination has been made, both the patient and prescriber will be contacted to discuss the application outcome and any next steps. Genentech medicines include: ACTEMRA (tocilizumab) GAZYVA (obinutuzumab) Rituxan (rituximab) ACTIVASE (alteplase) HEMLIBRA (emicizumab-kxwh) RITUXAN HYCELA (rituximab/hyaluronidase human) ALECENSA (alectinib) Herceptin (trastuzumab) Tarceva (erlotinib) Avastin (bevacizumab) KADCYLA (ado-trastuzumab emtansine) TECENTRIQ (atezolizumab) Cathflo Activase (alteplase) LUCENTIS (ranibizumab injection) TNKase (tenecteplase) COTELLIC (cobimetinib) OCREVUS (ocrelizumab) VENCLEXTA (venetoclax) Erivedge (vismodegib) PERJETA (pertuzumab) XOLAIR (omalizumab) for subcutaneous use Esbriet (pirfenidone) Pulmozyme (dornase alfa) Inhalation Solution ZELBORAF (vemurafenib) * The Genentech Patient Foundation does not provide free medicine in the instance of an administrative error or a coverage restriction such as a step edit. Some exceptions may apply. 1/4

4 PATIENT CONSENT INFORMATION (To be completed by the patient or their legally authorized person) Who may see and use my personally identifiable information (PII) I am directing my health care provider(s) and/or health care plan(s) to share my health information with Genentech. I authorize Genentech to use and share my health information about my treatment with Genentech medicine. This may include information about my diagnoses and prescriptions and health care plan benefits. I authorize my health information to be shared with Agents, affiliates and vendors who are assisting Genentech and my health care provider(s), health care entities, pharmacies and health plan(s) for the purpose of helping me apply for support programs and get my Genentech medicine, including: Talking to my health care plan to understand my benefits and coverage situation Understanding if I might be eligible for other types of coverage and financial assistance for my Genentech medicine Processing shipment of my Genentech medicine through a pharmacy Administrative purposes to support Genentech Access Solutions and the Genentech Patient Foundation Receiving my Genentech medicine If I receive free Genentech medicine from the Genentech Patient Foundation, I will not sell or give out this medicine since that is illegal. I am responsible to make sure these medicines are sent to a secure address when shipped to me, and I must control any Genentech medicine that I receive. What it means to sign this form By signing this form, I understand: I, as a patient or signer, have a right to obtain a copy of this form This Authorization shall be in effect for 3 years from the date of my signature or the date of last enrollment, whichever comes first, unless a shorter period is required by law. I understand that if I am a resident of the state of Maryland, this Authorization will be valid for no longer than 1 year from the date I signed it Once I sign this form and my PII is transferred to Genentech and/or the Genentech Patient Foundation, the Health Insurance Portability and Accountability Act (HIPAA) may no longer protect my PII since Genentech is not covered by HIPAA. We know how important your PII is, and are committed to keeping it safe. We only use and share information for purposes described on page 1 For purposes of an audit, the Genentech Patient Foundation could ask me for a copy of my IRS 1040 form or other proof of income I may refuse to sign this form. I can cancel this Authorization at any time, which means that Genentech will no longer use my PII, but this does not apply to PII already shared. If you wish to cancel after signing, please send a written notice to Genentech at the fax number on this page. If I do cancel, Genentech can no longer help me get my Genentech medicine through these support programs 2/4

5 ENROLLMENT FORM (To be completed by the patient or their legally authorized person) Patient / Legally Authorized Person Signature Patient Print patient first name Print patient last name / / Date of birth ZIP Code Signature of patient/legally authorized person (A parent or guardian must sign for patients under 18 years of age) Date signed Person Signing (if not patient) Print first name Print last name Relationship to patient Eligibility Information Note: The Genentech Patient Foundation requires the information below to track patient applications. How many people live in your household (include yourself)? Other: What range does your current household income fall into? Under $75,000 $75,000 $100,000 $100,001 $125,000 $125,001 $150,000 Over $150,000 (list exact $ amount) Communication Preferences Preferred Language: English Spanish Other: How do you prefer to receive information? (please check all that apply) Home phone*: ( ) - Cell phone*: ( ) - OK to leave a detailed message? (please check all that apply) Home Cell Do not leave message OK to send a text message? Yes No Best time to reach you via phone M-F: Morning Afternoon Alternate contact name (if applicable): Relationship to patient: Phone: ( ) - * By providing my phone number, I authorize Genentech to use auto-dialers, prerecorded messages and artificial voice messages to contact me. I understand that these calls/texts may mention the name of Genentech products or services, details about my insurance coverage and my doctor s name. I understand that I am not required to consent to being contacted by phone or text message as a condition of any purchase of Genentech products or enrollment in Genentech Access Solutions or the Genentech Patient Foundation. 3/4

6 ENROLLMENT FORM (Prescriber to complete) Patient Information Patient First Name: Patient Last Name: Date of Birth: / / Gender: Male Female Phone: ( ) - Address: City: State: ZIP: Patient Insurance (check one): Uninsured Insured, but Lack Coverage Insured, but Medicine Is Unaffordable If Insured, Name of Insurance Provider: Subscriber ID #: Prescriber Information Prescriber First Name: Prescriber Last Name: Prescriber NPI: Practice Name: Practice Address: City: State: ZIP: Contact Name: Phone: ( ) - Fax: ( ) - Shipment Information Shipment Options: Upfront Shipments (medicine is delivered to patient s home or practice through the foundation s pharmacy) Product Replacement (prescriber treats with their own inventory of medicine, which the foundation will replace) Shipment To: Patient Prescriber Site of Treatment: Site of Treatment Address: City: State: ZIP: Contact Name: Phone: ( ) - Fax: ( ) - Prescription Information Note: If preferred, you may attach a written prescription or submit the prescription electronically (please indicate below). Electronic prescriptions can be submitted through an e-prescribing software or an electronic medical record that has been certified by Surescripts. Query for MedVantx or AmeriPharm in Sioux Falls, SD NPI or NCPDP Primary Diagnosis Code: Secondary Diagnosis Code: Tertiary Diagnosis Code: Has the Patient Started Treatment? Yes No Drug Allergies (check all that apply): No Known Aspirin Penicillin Other: Other Medicines Prescribed: Genentech Medicine Requested Size/Strength Quantity Frequency/Directions Refills 1 year Other: Prescription Submission Method (if not completed above): Written Prescription Attached Prescription Submitted Electronically Prescriber Attestation By signing below, I am agreeing to the following: The Genentech medicine listed above is medically necessary for this patient I have received authorization to release the information above and other protected health information (as defined by HIPAA) to the Genentech Patient Foundation and its affiliates I will not seek reimbursement for free product provided to the patient My patient meets the criteria for the Genentech Patient Foundation I understand that Genentech reserves the right to modify or discontinue the program at any time and to verify the accuracy of information submitted If the indication for which you are prescribing a Genentech product is not listed in the FDA-approved label, you are prescribing the medicine for an unapproved use, meaning that the FDA has not approved the efficacy, dosage amount or safety of this medicine when used for such a use. The Genentech Patient Foundation may provide the medicine for your patient, based upon your medical order and within program requirements For insured patients, I understand that the Genentech Patient Foundation does not provide free drug in the instance of an administrative error or a coverage restriction such as a step edit. For certain products where the step edit may not be medically appropriate, as confirmed by the prescribing physician, the Genentech Patient Foundation may consider support following 1 level of appeal For prescribers in states with official prescription form requirements, such as New York, prescriptions must be submitted on an official state prescription pad along with this enrollment form Sign Here NPI=national provider identifier. Signature of Prescriber Date Here / / Date 2018 Genentech USA, Inc. So. San Francisco, CA All rights reserved. Printed in USA 4/4