Assistance& Reimbursement Guide

ASSOCIATION OF COMMUNITY CANCER CENTERS / 2016

Patient ASSISTANCE& REIMBURSEMENT GUIDE

$VVRFLDWLRQRI&RPPXQLW\&DQFHU&HQWHUV 7KLVSXEOLFDWLRQLVDEHQH¿WRIPHPEHUVKLS ASSOCIATION OF COMMUNITY CANCER CENTERS (ACCC)

Steven L. D’Amato, BSPharm, BCOP President

Christian Downs, JD, MHA Executive Director

Monique J. Marino Manager, Publications

Amanda Patton Manager, Communications

Jillian Kornak Writer, Editor

ABOUT THE ASSOCIATION OF COMMUNITY CANCER CENTERS The Association of Community Cancer Centers (ACCC) is the leading advocacy and education organization for the multidisciplinary cancer care team. Approximately 20,000 cancer care professionals from 2,000 hospitals and practices nationwide are affiliated with ACCC. Providing a national forum for addressing issues that affect community cancer programs, ACCC is recognized as the premier provider of resources for the entire oncology care team. Our members include medical and radiation oncologists, surgeons, cancer program administrators and medical directors, senior hospital executives, practice managers, pharmacists, oncology nurses, radiation therapists, social workers, and cancer program data managers. Not a member? Join today at accc-cancer.org/ membership or email: [email protected]. For more information, visit the ACCC website at accc-cancer.org. Follow us on Facebook, Twitter, LinkedIn, and read our blog, ACCCBuzz. ASSOCIATION OF COMMUNITY CANCER CENTERS Patient 2016 ASSISTANCE& REIMBURSEMENT GUIDE Financial Toxicity A conversation with Yousuf Zafar, MD, MHS, and Dan Sherman, MA, LPC 4 Accessing Co-Pay Assistance Opportunities By Ann Kaley Kline 10 PAP Flow Chart 16 PAP Quick Reference Guide 18 Pharmaceutical Company Patient Assistance & Reimbursement Programs

AbbVie 26 IPSEN Biopharmaceuticals 54 Amgen, Inc. 27 Janssen Biotech, Inc. 56 ARIAD Pharmaceuticals, Inc. 30 Lilly Oncology 59 Astellas Pharma US, Inc. 31 Merck 62 AstraZeneca 34 Novartis Pharmaceuticals Corporation 65 Bayer HealthCare Pharmaceuticals, Inc. 36 Pfizer, Inc. 68 Boehringer Ingelheim Pharmaceuticals, Inc. 38 Pharmacyclics, LLC 72 Bristol-Myers Squibb 40 Sandoz, Inc. 73 Celgene Oncology 43 Sanofi Oncology 74 Eisai Co., Ltd. 46 Seattle Genetics 76 Genentech, Inc. 48 Taiho Oncology 78 Incyte Corporation 51 Takeda Oncology 79 Insys Therapeutics, Inc. 53 Teva Oncology 82

Other Patient Assistance Programs & Resources

Agingcare.com® 83 NeedyMeds 87 BenefitsCheckUp® 83 Partnership for Prescription Assistance 87 CancerCare® 83 Patient Access Network Foundation 88 CancerCare® Co-Payment Assistance Foundation 84 Patient Advocate Foundation 89 Cancer Financial Assistance Coalition 85 RxAssist 90 Co-Pay Relief 85 RxHope™ 91 HealthWell Foundation 85 Rx Outreach® 91 The Leukemia & Lymphoma Society 86

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 1 Patient Assistance and Reimbursement Assistance Programs by Drug or Product Abraxane® (paclitaxel protein-bound particles) for injection 43 Leukine® (sargramostim) 74 Actiq® (oral transmucosal fentanyl citrate) [C-II] 82 Lonsurf® (trifluridine and tipiracil) tablets 78 Adcetris® (brentuximab vedotin) for injection 76 Lupron Depot® (leuprolide acetate for deposit suspension) 26 Afinitor® (everolimus) tablets 65 Lynparza® (olaparib) 34 Akynzeo® (neutpitant/palonosetron) 46 Mekinist® (trametinib) tablets 65 Alecensa® (alectinib) capsules 48 Mozobil® (plerixafor) for injection 74 Alimta® (pemetrexed for injection) 59 Neulasta® (pegfilgrastim) 27 Aloxi® (palonosetron hydrochloride) 46 Neumega® (oprelvekin) 68 Aranesp® (darbepoetin alfa) 27 Neupogen® (filgrastim) 27 Arimidex® (anastrozole) 34 Nexavar® (sorafenib) tablets 36 Aromasin® (exemestane) tablets 68 Ninlaro® (ixazomib) capsules 79 Avastin® (bevacizumab) 48 Nplate® (romiplostim) 27 Bendeka™ (bendamustine hydrochloride) for injection 82 Odomzo® (sonidegib) 65 Blincyto™ (blinatumomab) 27 Opdivo® (nivolumab) 40 Bosulif® (bosutinib) tablets 68 Perjeta™ (pertuzumab) 48 Camptosar® (irinotecan hydrochloride injection) 68 Pomalyst® (pomalidomide) 43 Caprelsa® (vandetanib) 34 Portrazza™(necitumumab) 59 Casodex® (bicalutamide) 34 Procrit® (epoetin alfa) 56 Cotellic™ (cobimetinib) tablets 48 Prolia® (denosumab) 27 Cyramza® (ramucirumab) 59 Promacta® (eltrombopag) tablets 65 Darzalex™ (daratumumab) 56 Revlimid® (lenalidomide) 43 Doxil® (doxorubicin HCl liposome injection) 56 Rituxan® (rituximab) 48 Elitek® (rasburicase) 74 Sandostatin® (octreotide acetate) for injection 65 Ellence® (epirubicin hydrochloride injection) 68 Sandostatin LAR® Depot (octreotide acetate 65 Eloxatin® (oxaliplatin) for injection 74 for injectable suspension) Emcyt® (estramustine phosphate sodium capsules) 68 Sensipar® (cinacalcet) 27 Emend® (aprepitant) 62 Somatuline® Depot (lanreotide) for injection 54 Emend® (fosaprepitant dimeglumine) for injection 62 Sprycel® (dasatinib) 40 Empliciti™ (elotuzumab) 40 Stivarga® (regorafenib) tablets 36 Epogen® (epoetin alfa) 27 Subsys® (fentanyl sublingual spray) 53 Erbitux® (cetuximab) 40, 59 Sutent® (sunitinib malate) 68 Erivedge™ (vismodegib) 48 Sylatron™ (peginterferon alfa-2b) for injection 62 Exjade® (deferasirox) tablets 65 Sylvant® (siltuximab) 56 Farydak™ (panobinostat) capsules 65 Synribo® (omacetaxine mepesuccinate) for injection 82 Faslodex® (fulfestrant) 34 Tafinlar (dabrafenib) capsules 65 Femara® (letrozole) tablets 65 Tagrisso® (osimertinib) 34 Fentora® (fentanyl buccal tablet) [C-II] 82 Tarceva® (erlotinib) 31, 48 Gardasil (Quadrivalent Human 62 Tasigna® (nilotinib) tablets 65 Papillomavirus Recombinant Vaccine) Taxotere® (docetaxel) for injection 74 Gardasil®9 (Human Papillomavirus 9-valent Vaccine, Recombinant) 62 Thalomid® (thalidomide) 43 Gazyva™ (obinutuzumab) 48 Thymoglobulin® (anti-thymocyte globulin [rabbit]) 74 Gemzar® (gemcitabine hydrochloride) 59 Temodar® (temozolomide) 62 Gilotrif™ (afatinib) 38 Gleevec® (imatinib mesylate) tablets 65 Torisel® (temsirolimus) for Injection 68 Granix™ (tbo-filgrastim) for injection 82 Treanda® (bendamustine HCl) for injection 82 Halaven™ (eribulin mesylate) 46 Trisenox® (arsenic trioxide) for injection 82 Herceptin® (trastuzumab) 48 Tykerb® (lapatinib) tablets 65 Hexalen® (altretamine) capsules 46 Vectibix® (panitumumab) 27 Ibrance® (palbociclib) 68 Velcade® (bortezomib) for injection 79 Iclusig™ (ponatinib) 30 Vidaza® (azacitidine) 43 Idamycin® (idarubicin hydrochloride) for injection 68 Votrient™ (pazopanib) tablets 65 Imbruvica® (ibrutinib) 72 Xalkori® (crizotinib) capsules 68 Imlygic™ (talimogene laherparepvec) 27 Xeloda® (capecitabine) 48 suspension for intralesional for injection Xgeva™ (denosumab) 27 Inlyta® (axitinib) tablets 68 Xofigo® (radium Ra 223 dichloride injection) 36 Intron® A (interferon alfa-2b, recombinant) for injection 62 Xtandi® (enzalutamide) capsules 31 Iressa® (gefitinib) 34 Yervoy® (ipilimumab) 40 Istodax® (romidepsin) for injection 43 Yondelis® (trabectedin) 56 Ixempra™ (ixabepilone) 40 Zaltrap® (ziv-aflibercept) 74 Jadenu™ (deferasirox) tablets 65 Zarxio™ (filgrastim-sndz) 73 Jakafi® (ruxolitinib) tablets 51 Zelboraf® (vemurafenib) 48 Jevtana® (cabazitaxel) 74 Zinecard® (dexrazoxane) for injection 68 Kadcyla® (ado-trastuzumab emtansine) 48 Zoladex® (goserelin acetate) 34 Keytruda® (pembrolizumab) 62 Zolinza® (vorinostat) 62 Kyprolis® (carfilzomib) for injection 27 Zykadia™ (ceritinib) capsules 65 Lenvima™ (lenvatinib) capsules 46 Zytiga® (abiraterone acetate) 56

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TABLE OF CONTENTS

Financial Toxicity: A conversation with Yousuf Zafar, MD, MHS, and Dan Sherman, MA, LPC

Dr. Zafar. My primary goal is to make sure that any treatment I provide a patient first does no harm. Traditionally, we’ve thought about harm wareness has grown among both the as physical harm, the physical side effects that patients public and providers about the risks can experience as a result of treatment. More and more, of financial toxicity for patients with however, financial harm has to be a part of that con- cancer and their families. At the same sideration as well. So as an oncologist, if I’m prescribing time, as healthcare reform evolves, a treatment for a patient, considering both the poten- Aunderstanding the financial implications of care has tial for physical and financial harms is well within become increasingly complex. ACCC asked members my purview. of the Financial Advocacy Network (FAN) Advisory Committee Yousuf Zafar, MD, MHS, associate professor How do you think providers can do a better of Medicine, Duke Cancer Institute, and Dan Sherman, job in this area? MA, LPC, clinical financial consultant, The Lacks Cancer Center, to share their perspectives on why addressing QDr. Zafar. I think the first step is engaging patients on financial concerns with cancer patients is important the topic. There is evidence that just discussing finan- and how the role of financial counselors is evolving. cial harm or financial toxicity with their doctor can reduce the distress that patients feel. So really what this Why is it important that we do a better job means is that patients like to know that they and their of helping patients with financial issues doctor are on the same page when it comes to what the related to their cancer treatments? patient is experiencing. That’s the first step. The second Q is being aware of the resources around us that can help. As an oncologist I don’t think my job is to know how

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...if I’m prescribing a treatment for a patient, considering both the potential for physical Financial Toxicity: and financial harms is well within my purview. A conversation with — Dr. Zafar Yousuf Zafar, MD, MHS, and Dan Sherman, MA, LPC

much every MRI or every our patients is addressed at a drug I prescribe is going to cost, level that truly meets the needs of our but I should know where I can go for help. So under- patients?” We would never accept using treatment standing that I need to involve my colleagues that I work models developed 20 years go to address the complexity with—my pharmacists, social workers, and financial of cancer care when new treatments are far superior to counselors—and know where those resources are to the old ones. Far too often, however, we accept this in the direct patients to when they ask is very important. realm of financial advocacy for our patients.

Dan, from the financial navigator’s perspec- So how do we address this better? I think we need to tive, why is it important to do a better job start looking at having the financial navigator trained helping patients with these issues? and not just “learning on the job.” We also should look Q beyond the “20 years ago” solutions of Medicaid and Dan Sherman. Improvement in this area is needed charity care. It’s not that these solutions are wrong for because of what Dr. Zafar and researchers like him are some patients, but they do not solve the problem for a finding regarding the alarming statistics of financial high percentage of our patients. The financial navigators toxicity. We now know that financial toxicity and related should also be critical members of the multidisciplinary anxiety are the top concern of oncology patients. The team. They need direct access to the oncologist, RNs, and main concern is no longer dying from the disease; it’s social workers so that when the treatment plan is gener- the financial worries that consume our patients. This ated, the pending financial toxicity that will soon occur is financial toxicity also creates a barrier in providing care addressed within the treatment plan. and unfortunately patients refuse the recommended treatments because we have failed the patients when Why has it become more difficult to identify it comes to addressing this issue well. We also know we those patients at risk for financial toxicity? need improvement in this area because even though most hospital settings that provide oncology care have QDr. Zafar. Speaking as a researcher who has investi- financial counselors who have been tasked to deal with gated this topic, it’s difficult to identify patients [at this problem, nonetheless, the problem remains. So it’s risk] because the traditional markers of socioeconomic fair to ask, “What are we doing wrong?” and “How can disparity don’t apply when it comes to financial toxicity. we improve so that the financial toxicity we create for It’s not like we can look at income, or zip code, or race

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as markers to find patients who are at risk for receiving toxicity, allows us to proactively address the issue with sub-par care as is traditionally done in health dispari- the patient. ties research. The problem is that the patients who are at greatest risk are the patients who have poor The model of financial advocacy that I use when meeting quality insurance, and it’s very difficult to know who with patients is twofold: you address financial toxicity has poor quality insurance until they are hit with that by (1) optimizing the patients’ health insurance coverage catastrophic illness. That is the only time the patient and (2) optimizing external assistance programs. For this really finds out they are under-insured. That is why it is model to be effective, it’s essential to address the pending difficult to identify patients who are at risk for financial toxicity prior to treatment. This accomplishes two things: toxicity unless you ask some very pointed questions first, it reduces the emotional distress of the patient and/ about their insurance coverage. or family and it does this as early on in the process as possible, and second, it reduces the out-of-pocket respon- From the provider perspective, why is it sibilities for the patient. This results in a win for both the critical to identify patients at risk? patient and provider. The patient receives the care they need with less financial distress and the provider is able QDr. Zafar. When I make patient treatment decisions, I to collect on the services provided. do so primarily on the immediate oncologic benefit to that patient. How is this going to help treat the patient’s To aid in early identification of patients at risk for finan- cancer? But when cost to the patient is not a part of that cial toxicity, financial advocates must have a basic under- consideration, and I don’t know how much that patient standing of the clinical needs of patients. For example, I might pay out of pocket for that treatment, I could be financially navigate a patient diagnosed with DCIS very causing that patient a great deal of financial harm. And differently than a patient with multiple myeloma. These I have done that and I’ve spoken previously about it. I patients have different needs on a different time table. know of specific patients where I’ve given them what I Insurance optimization may be easier to accomplish with believe to be the best treatment for their cancer, but as a one diagnosis compared to the other. So incorporating result they have incurred thousands of dollars of medical the clinical needs of the patient plays a significant role in debt because I did not address their potential for finan- the early identification process. I often seek out patients cial toxicity. with advanced stage disease as this type of diagnosis often results in financial distress. These patients also Dan, from your perspective, why is it critical run the risk of losing their health insurance if they have to identify the patients at risk? coverage through a group policy from their employer. Early intervention in these cases is vital to protect them QDan. It is essential to know which patients will most from the pending financial toxicity coming their way. likely experience financial toxicity because early intervention is critical to resolving the issue. If we wait for the Dr. Zafar. Dan is definitely on the frontlines of inter- medical bill to arrive 60-90 days later, the solutions that vening on this problem. As a provider, when I think about were available early on will most likely no longer be an what it means to intervene on financial toxicity, again, option. I believe the financial advocacy process should I’m talking about patient engagement. While getting the replicate the medical model. We provide anesthesia prior patient to the financial counselor is where they will get to surgery not after. Yet with financial advocacy, we the help oftentimes, as Dan mentioned earlier, the only typically intervene after treatment has been initiated. person who can identify those patients is the physician We wait, and the toxicity created can no longer be allevi- who is about to prescribe the treatment. So in my mind, an ated. Early identification of patients at risk for financial intervention is as simple as asking a patient, “Do you have

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prescription drug coverage?” In fact that is how I could recently stated, “Dan, we should treat every patient as if have avoided one of my patients facing thousands of dollars they do not have insurance. It makes us think through in out-of-pocket costs by asking that one simple question. what we are doing to the patient.” If our providers started to think this way we would come a long way in However, from a research perspective, we are developing decreasing financial distress for our patients. some more detailed and multi-faceted interventions that promote patient engagement around the cost of care Given the Commission on Cancer with their providers, which can help educate patients Standard mandating distress screening, and help them find the resources that they need. In the would ensuring that financial issues were meantime, I would advocate that tomorrow in clinic included in this screening help? providers ask the question without being afraid that Q they don’t know what the answer is. Dr. Zafar. I’m not sure distress screeners are as effective as we think they are. Many times, particularly in a Unfortunately cancer services are still frag- busy clinic, they are not often reviewed the way they mented in some communities. How can the should be and it sort of falls into the mix of all the other cancer care team best work together to address symptoms that patient may be screened positive for. The unwanted side effects of financial toxicity? problem in screening for financial toxicity, or any side Q effects for that matter, is how do you effectively capture Dan. When you have a fragmented healthcare system, and screen patients? And when do you do it? What is the task of providing care without causing financial the right time to do it so that it impacts the treatment distress becomes more difficult. I am blessed to work in decision-making? I think it’s a step in the right direction a facility where all the services are provided under the to mandate symptom screening at our institution and same roof. This makes it more practical for one person we already include financial distress as part of that, but to have the responsibility of communicating the finan- I don’t think we have good evidence as to how beneficial navigation plan to all the providers. This is not the cial that is yet. That is part of what I’m working on is to case in many community cancer programs. From my see whether or not screening and identifying patients perspective it comes down to effective communication, and prompting the physician, based on the patient’s providers being more aware of the problem and having screening results, is helpful. all the different departments (Medical Oncology, Radia- tion Oncology, and Surgery) consider this problem to be How would you address concerns about a high priority to deal with. I would recommend that disrupting or adding to the physician you have a screening process where you can identify the workflow and how providers and financial most likely patients who will experience financial toxi- navigators can best work together? city. This information will then need to be communicatedQ to the financial advocate who then can address prob- Dr. Zafar. I want to be clear that this is just an example. lems as early as possible. Many of the financial naviga- It’s not going to fix the problem by any means, but tion steps can be managed over the phone if necessary. it might help identify the issue for some and it is an The key again is early intervention. In facilities where example that resonates with a lot of providers. For fragmented care is occurring, the problem is often that example, in my clinic, if I’m going to prescribe a patient the right person does not know that a problem exists. an oral anti-cancer drug, I will first stop by my phar- Focused attention on identifying the patient at risk for macist’s office before going into the patient’s room and financial toxicity is therefore recommended in this type let her know that this patient is going to get an expen- of setting. As one of the physicians in our cancer program sive prescription. She will start looking up the patient’s

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insurance to determine the patient’s co-pay amount. the medication, it improves communication between While she is doing this, I am talking to the patient about the provider and support staff, and it decreases finan- the benefits and physical risks of that drug. When I’m cial distress for the patient. finished, the pharmacist will come in the room and tell the patient what the drug will cost and ask whether this Dr. Zafar’s solution is that before you walk into the is affordable. If not, I get pulled back for another discus- room, you are starting to look at whether a financial sion of treatment alternatives. The process is actually barrier exists. very efficient. One other point I’d like to make: There is some preliminary data from one of my colleagues at At our program, the financial navigator would be in close Duke who has found that a discussion about personal communication with the medical oncologist, and would financial burden related to cancer treatment on average try to address the co-pay issue while the patient was still lasts about 1 to 2 minutes. here so that the patient leaves with a solution provided.

Dan, from your perspective, how does that What are some of the factors fueling communication work? financial toxicity for patients with cancer?

QDan. Dr. Zafar’s approach is pivotal, especially with oral QDr. Zafar. I think there are three factors that are contrib- oncolytics, which comprise around 30-35 percent of the uting to higher costs. First, the drugs that we are oncology pipeline. We also need to be aware that on prescribing are more expensive. Second, we’re using average 40-50 percent of your patient population will be more of them and patients are on treatment for longer. in Medicare Part D. When you combine these new expen- Third, there is greater cost sharing. Together all of these sive oral cancer drugs (usually costing $8,000- $10,000 a factors are coming to a head at the same time. month) and Medicare Part D, we know that the patient will most likely experience financial toxicity. A large In terms of cost sharing, deductibles have doubled, number of these patients will end up refusing to fill their premiums have increased tremendously in the past prescription when they discover that they face a co-pay decade, and particularly important for our patients, we of more than $2,000 the first time they try to fill it. are seeing a huge surge in the number of multi-tiered formularies. A recent Kaiser study that found that the At our facility we have the medical oncologists contact number of multi-tiered formularies had increased to the financial navigator when they prescribe high- about a quarter of plans surveyed. This is particularly dollar oral oncolytics. We then verify the benefits and important for our patients because many of the expen- attempt to fill the prescription while the patient is still sive anti-cancer medications and some of the expen- at the facility. With this process we will know, while sive supportive care medications that we prescribe the patient is present, if we need to address a co-pay fall into the higher tiers, resulting in more co-pays for problem. Currently there are several foundations that our patients. So I think there is a shift toward patients provide instant approvals for co-pay assistance so the bearing a greater cost burden. problem can often be solved before the patient leaves the cancer center. We also have a list of specific diag- And for some disease sites, patients have noses for which high-dollar oncolytics are often no choice but to reach for those higher cost, prescribed, so that when a patient comes in with that higher-shelf formulary drugs. specific diagnosis, we will often proactively analyze Q the problem while the oncologist is meeting with the Dr. Zafar. Right. When we talk about cost sharing, this patient. This process expedites the patient’s access to concept was first developed to reduce use of unneces-

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sary care. So tiered formularies become important when have shown that more than half the time, when patients patients have alternatives. For example, if patients are talk to their doctors about cost, those costs are reduced thinking about buying two separate medications—one without changing care. for hypertension and one for hyperlipidemia—vs. buying a much more expensive combined pill. But for cancer What about the family’s involvement in patients that option does not exist. There is one drug this issue? and there is no alternative other than the option of not receiving treatment. For many patients that is not a QDan. The family’s involvement plays an important role palatable option. when it comes to customizing a financial navigation plan for the patient. We should acknowledge that the Dan. To deal with financial toxicity we need to move patient is overwhelmed with multiple issues on the day away from the one-size-fits-all mentality. This mindset, of consult. Adding in financial navigation services is unfortunately, is dominant in the medical financial critical, but at the same time, effective financial naviga- advocacy discipline. We don’t treat every lung cancer tion services are often complex. It may be challenging patient in the same manner, as it depends on the type for patients who are already overwhelmed to under- of stage of the cancer diagnosis. The treatments depend stand and absorb new terms and issues such as max on the type and stage of the disease. However, with out-of-pocket, co-insurance responsibilities, prior autho- financial counseling, we often funnel patients through rization requirements, and open enrollment guidelines. the same financial assessments and provide the same So I find it very helpful when family is present. Often solutions to all the patients asking for help, which often family will play a significant role in helping me guide the ends in attempts to apply for Medicaid, charity, and patient to improved coverage for his or her treatments. co-pay assistance. This “one-size-fits-all” approach may There are also times when I will educate patients on how help some patients, but we need to recognize that it does they can avoid large out-of-pocket responsibilities by not work for all. If it did, financial distress would not be purchasing health insurance policies that will provide the number one concern of oncology patients. We need improved coverage for their care. Patients can often do to start addressing the problem by customizing the this when looking at ACA policies or Medicare plans. At patient’s financial navigation plan. We do this with all times these policies come with a higher premium that other aspects of their care but we don’t do it with some- the patient may not feel is affordable. When family is thing as important as their financial well-being. present and also informed, they may choose to assist their loved one with the increased cost of the premium. Dr. Zafar. When I talk to oncologists about this topic, one For all of these reasons, seeing the patient on the day of of the first responses I often get is “I have no idea where consult is beneficial, and family is usually present on this to start. I don’t know what anything costs. How am I very important day. y supposed to help my patients if I don’t have any answers?”

I think this is a reasonable concern. We don’t have a lot of answers. There is not a lot of price transparency in our healthcare system. But that shouldn’t prevent us from initially engaging our patients on this topic. We’ve got evidence to suggest that we’re already doing it. We are already decreasing some of the cost burden that patients are facing by engaging people like Dan and engaging our pharmacists early on in the process. Our studies

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o-pay card programs are designed to make Confusion for Hospital it easy for patients to use awarded funds Billing & Payment Offices and apply those funds to patient balances Adding to the general confusion resulting from deductible or co-insurance between the use of automated and amounts due that must be met before manual billing processes, co-pay Cinsurance pays 100 percent. To participate in a co-pay cards (which are often handed card program, patients apply (by phone, online, or via out to patients by physician faxed applications) to the participating drug companies. offices) look very similar to The drug manufacturer presents patients with a co-pay credit cards or health savings assistance card and—once funds have been approved— account (HSA) cards (which the company provides an approval code so that patients also look like credit cards). can use the card to pay the funds into their account. When MSTI researched Sounds easy, right? Not quite. how to set up an effective co-pay card program, A colleague shared one anecdotal account of a patient we discovered that ACCESSING who was given a co-pay assistance card and then some patients had tried used the funds to buy a refrigerator. While that may doing this on their have indeed been a pressing need, if the goal is to use own and had used the the program to help patients pay down their patient co-pay cards to call up balances, I suggest that providers offer to “hold” co-pay Customer Service to cards and process payments for patients to help them make payments. Unfor- avoid temptation to spend the money elsewhere. tunately patients didn’t know to identify that ASSISTANCE Complexity of Applying Payments they were using a co-pay Billing for infusion services is a complex process. St. card, and our Customer Luke’s Mountain States Tumor Institute (MSTI) bills Service Department doesn’t Opportunities for infusion services on a recurring account once each identify the type of card month. On one hand, this process works well for patients used or the type of funds, so who receive just one monthly bill for their infusion these payments were often services. On the other hand, it makes the process of assumed to be private payments applying payments to specific infusion dates tricky. or HSA funds. Additionally our billing and cash management office often takes payments and applies them to the oldest To make the co-pay cards work for date of service owed—an automated function. When our patients, we saw a need for educa- making specific payments, such as a payment from a tion and streamlined processes. co-pay card program, a manual process is needed to ensure the money is applied correctly.

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By Ann Kaley Kline

ACCESSING

ASSISTANCE Opportunities

To make the co-pay cards work for our patients, we saw a need for education and streamlined processes.

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Manpower Needed to Access Funds Using this hypothetical scenario, I estimated what the In addition to the challenge of billing and cash manage- savings would be if each of those 1,110 patients used ment applying payments to access co-pay card funds, a co-pay card. As we all know, payment collection for another difficulty we encountered was the manpower cancer patients is costly and can often result in bad debt needed to actually submit claims to these companies to write-offs or charity write-offs. By accessing the avail- obtain the funds. Once a patient applied to the co-pay able co-pay programs, I estimated a conservative reduc- program, was approved, and then awarded funds, claims tion in write-offs of $240,000—an amount that could be need to be submitted to obtain payment. To receive considered revenue back into the health system instead payment, the following items are needed: of going to write-offs.

• The actual itemization of charges that include the Communicate the Benefits date of service, drug name, and CPT Code. In other Once I could show hospital leadership the patient need words, a copy of the bill from the infusion center or and the potential funds to be realized from use of co-pay hospital where the services were rendered. cards, I had to find the manpower needed to actually • The patient’s Explanation of Benefits (EOB), showing obtain the funds. I looked to our Patient Financial Advo- that the claim was submitted to the patient’s cate team for help. Patient volumes were increasing, insurance, how those charges were processed by and so was the team’s workload. At the time, our patient the patient’s plan, and the out-of-pocket cost to the financial advocates were responsible for: patient attributed by the insurance. • Financial screening Getting patients to bring in the appropriate documenta- • Authorizations tion can be challenging, especially at a time when they • Federal, state, local, and hospital assistance are often overwhelmed with the demands of treatment. applications • Co-pay assistance In 2013 I moved from the role of a patient financial • Pharmacy assistance advocate to my current role as manager of Revenue • FMLA, Disability, and/or Cancer Claim Paperwork. and Reimbursement for St. Luke’s MSTI. One of my goals in this new position was to figure out how to Looking at this workload, it was clear that adding co-pay effectively manage the various co-pay card programs. assistance claims would overwhelm our already busy My senior director is a great mentor who encouraged patient financial advocates, so I looked at what could be me to spend time thinking about how our co-pay done to lighten the team’s load. My proposed solution: to process could be improved. hire a person to submit all patient claims to co-pay card programs and help the patient financial advocacy team Identify the Need with other tasks as needed. The next step was to obtain My first step was to research all of the various co-pay administrative approval for this new position. programs our patients could possibly access. I looked at how many of our patients with commercial insurance At St. Luke’s MSTI, administration requires management had actually used the drugs covered by these programs to submit requests for staff or other needs using a Busi- in the past fiscal year, identifying about 1,110 patients. ness Case or SBAR (Situation, Background, Assessment, Then I asked a financial analyst to help calculate a “what and Recommendation). Thus far, I had the Situation and if” scenario: What if these patients had not yet met their the Assessment, and now I needed to put the Recom- out-of-pocket needs, and what if those out-of-pocket mendation together. I went to our Human Resource costs averaged about $3,000 per patient. Department and found a current job description called

12 / ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org TABLE OF CONTENTS

authorization specialist that I felt might work for this • CPT codes new role I was developing. (This was advantageous as • Contractual adjustments making a new job description requires a lot more time • How to recognize when infusions had been billed and effort than simply adopting a current job descrip- to insurance or not; she could even reach out to tion to meet new needs.) The work that I was proposing the billing office when those claims needed to for this staff role had little to no patient interaction and be rebilled. would mostly be completed in an office and/or clerical- type setting, so the authorization specialist job descrip- These skills helped me understand that this role wasn’t tion appeared to be a good fit. simply a clerical role and that billing knowledge was a critical component to following up on our co-pay I proposed this staff role would have the following card claims. responsibilities in order of work priority:

• Co-pay assistance claims Another discovery we made along our journey: our • Drug replacement requests billing office had actually set up a generic insurance plan • Cancer claim submissions for external foundation assistance for organizations • Imaging authorizations. such as the Patient Access Network Foundation. As our new authorization specialist began to interact more and Taking over drug replacement requests and cancer claim more with our billing and cash management offices, they submissions for our patients and backing up the patient started bringing these payments to her as they came in, financial advocacy team during unexpected absences, and we helped improve these generic insurance plans so holidays, and other staffing shortages would lighten the that funds were applied against the appropriate patient load for the entire team and also help to justify making balances. As part of this process, we determined that the it an FTE position, allowing our co-pay card program to authorization specialist should also manage foundation grow. Bottom line: I justified adding one FTE with the assistance applications, so now our patient financial potential annual gain of $240,000. advocacy team sends those approved applications to her as well. Discovery Along the Way Administration approved my request, and I began Outcome recruiting my authorization specialist. At first I focused MSTI is still tweaking the authorization specialist role on the fact that the role was clerical and would not and its co-pay program. Our patient financial advocacy require extensive experience—just solid organizational team is working hard to ensure patients apply to the skills to stay current with claims and to track them appropriate co-pay assistance programs and Founda- for payment. In January 2015, I hired a staff member tions. (We’ve often said that adding a new process to from our billing office. She turned out to be a great our workload can take six months to a year to become fit, bringing to the table additional qualifications that routine.) My hope is that we have fine-tuned the process helped her succeed in this new role. For example, our enough that we are ready for January 2016 when most new authorization specialist had internal knowledge of patients start their new insurance plan year. MSTI’s billing software and therefore could pull claims and electronic remittance advices once those claims We have added a notification step in to our process to were processed to submit to the appropriate co-pay review all patients for financial assistance whenever card program. Further, as a former insurance follow-up patients receive New Treatment, Regimen Change, or employee, she understood: Treatment Orders by their physician. The team looks up

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the patients’ benefits at the time of the order, determines We would like drug manufacturers to set up online if they qualify for a co-pay card or foundation assistance, processes so that we could upload claims and documen- and notes their findings in the patients’ medical record. tation in a real-time environment. Web-based co-pay We’ve found that this extra process is a great opportunity programs would allow us to see the claims submitted, to temperature check patient benefits. Recently, we imple- where those claims are in processing, when payment mented an incentive program wherein every quarter I will be submitted, and the amount of funds each patient send out a report from each clinic (we have five infusion has left. Currently the only way to get this information is clinics and three rural clinics), identifying the team that for the authorization specialist to call and ask the appro- submitted for the most patient financial assistance that priate co-pay assistance program. One interesting finding: quarter. Interestingly, bagels and coffee have proven to many individuals at these co-pay assistance programs be a great incentive and assistance is up! have little to no billing knowledge, making it challenging to have robust discussion. As the authorization specialist and I have spread the word about our services and the co-pay assistance In short, St Luke’s MSTI has developed an effective program, our healthcare system has met with us about process for applying for co-pay assistance and ensuring replicating what we are doing at other service lines, that staff are appropriately applying funds to the appro- such as Rheumatology. Developing the co-pay program priate accounts, and now we are waiting for has also improved our understanding of how we take pharmaceutical manufacturers to speed up their payments from our patients and the importance of payment processes. We have a large amount of co-pay identifying where those payments are coming from funds awaiting payment, and they are slow in coming and where funds are being applied. We may change into our cancer program. I am working to engage the the authorization specialist job description to medica- various drug manufacturers in conversation to see tion specialist, which is better aligned to what this staff how we can encourage them to set up online support member is doing. systems to access payments faster.

Future Plans Would I do this again? You bet! Our patient financial Our current co-pay card process is manual, and we would advocacy team has received strong support from the new like to see that improved. The authorization specialist authorization specialist position—as has our patients faxes all claims and retains fax confirmation as proof of who truly appreciate the additional help with their out of claim submission. The process is not ideal; for example, pocket costs. The cost of adding this new FTE position to one drug manufacturer randomly sends a return fax our team is already being recouped in pending payments, stating the claim was received but with no patient identi- so the program is a win for all. More to come as we fiers. (A second fax often comes a day or so later.) continue to refine this position and program.y

Ann Kaley Kline is manager, Revenue & Reimbursement at St. Luke’s Mountain States Tumor Institute, Boise, Idaho.

14 / ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org TABLE OF CONTENTS THANK YOU / to our supporters

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PAP /f low chart

STEP 1. Provider writes chemotherapy order for patient.

STEP 3. Staff identifies the patient’s financial status and follows the appropriate flow chart below.

Identify if patient qua- Fill out forms for all Identify if foundation Fill out forms for NO INSURANCE lifies for any programs programs. Complete funding is available for any foundation funding (SSDI, Medicaid, etc.). forms for companies that drugs not replaced. that is available. Identify if replacement have a replacement pro- drugs are available. gram if patient qualifies.

Verify benefits. Verify drugs are Identify if replacement Identify patient’s MEDICAID indicated for diagnosis drugs are available if responsibility. PROGRAM and authorize if necessary; will need to necessary. appeal to receive drugs.

Verify benefits. Verify drugs are Identify if replacement Identify patient’s MEDICARE indicated for diagnosis. drugs are available if responsibility. ONLY necessary; will need to appeal to receive drugs.

Verify benefits. Verify drugs are Identify if replacement Identify patient’s MEDICARE & indicated for diagnosis. drugs are available if responsibility; if SUPPLEMENTAL necessary; will need to none, start treatment. appeal to receive drugs.

Verify benefits. Verify drugs are Identify if replacement Identify patient’s MEDICARE & indicated for diagnosis drugs are available if responsibility. SECONDARY and authorize secondary necessary; will need to insurance if necessary. appeal to receive drugs.

Verify benefits. Verify drugs are Identify if replacement Identify patient’s MEDICARE indicated for diagnosis drugs are available if responsibility. ADVANTAGE and authorize secondary necessary; will need to insurance if necessary. appeal to receive drugs.

Verify benefits. Verify drugs are Identify if replacement Identify patient’s OTHER indicated for diagnosis drugs are available if responsibility. GOVERNMENT and authorize secondary necessary; will need to insurance if necessary. appeal to receive drugs. PROGRAMS

Verify benefits. Verify drugs are Identify if replacement Identify patient’s MANAGED CARE indicated for diagnosis drugs are available if responsibility. and authorize secondary necessary; will need to insurance if necessary. appeal to receive drugs.

Verify benefits. Verify drugs are Identify if replacement Identify patient’s COMMERCIAL & indicated for diagnosis drugs are available if responsibility. INSURANCE and authorize secondary necessary; will need to EXCHANGES insurance if necessary. appeal to receive drugs.

16 / ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org TABLE OF CONTENTS

STEP 2. Chemotherapy order is sent to finance staff.

STEP 3. Staff identifies the patient’s financial status and follows the appropriate flow chart below.

Identify if patient Create payment qualifies for charity plan for any balance care within the clinic (if available) or or institution and collect balance. complete paperwork.

Collect out-of-pocket costs.

Identify if foundation Fill out forms for Identify if patient Create payment assistance is available. foundation funding qualifies for charity plan for any balance that is available. care within the clinic (if available) or or institution and collect balance. complete paperwork.

If patient has Fill out forms for If patient qualifies, If any balance, responsibility, foundation funding send in EOB and/or create payment identify if foundation that is available. anything else to help plan for any balance assistance is available. verify amount for (if available) or foundation to pay. collect balance.

Identify if foundation Fill out forms for If patient qualifies, If any balance, assistance is available. foundation funding send in EOB and/or create payment that is available. anything else to help plan for any balance verify amount for (if available) or foundation to pay. collect balance.

Identify if manu- If no manufacturer Fill out forms for If patient qualifies for Process payment If any balance, facturer assistance assistance, then foundation funding manufacturer or using co-pay card create payment is available and fill identify if foundation that is available. foundation assistance, or whatever form plan (if available) out forms if applicable. assistance is available. send in EOB and/or of payment the or collect anything else to help program has. balance from verify amount owed. patient.

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PAP /quick reference guide

BENEFIT VERIFICATION AND DRUG COMPANY AUTHORIZATION CO-PAY FOUNDATION DRUG NAME BRAND NAME DRUG COMPANY SUPPORT ASSISTANCE ASSISTANCE 13-cis-Retinoic Acid Accutane X 2-CdA Leustatin D, H 2-Chlorodeoxyadenosine Leustatin D, H 5-Azacitidine Vidaza Celgene X D,H,P X 1.800.931.8691 www.celgenepatientsupport.com 5FU Adrucil D, H 6-Mercaptopurine Purinethol H X 1.800.675.8416 www.healthwellfoundation.org 6-MP Purinethol H X 1.800.675.8416 www.healthwellfoundation.org 6-TG Thioguanine Tab X X 1.855.382.1280 https://rebates.com/thioguanine-coupon/ 6-Thioguanine Thioguanine Tab X X 1.855.382.1280 https://rebates.com/thioguanine-coupon/ Abiraterone acetate Zytiga Janssen Biotech X X 1.855.998.4421 http://www.janssenaccessone.com/pages/zytiga/index.jsp Ado-trastuzumab emtansine Kadcyla Genentech X X D,H,P X 1.866.422.2377 www.genentech-access.com/hcp Afatinib Gilotrif Tablets Boehringer Ingelheim X P 1.877.814.3915 https://www.gilotrif.com/solutions_plus.html Alemtuzumab Campath Genzyme X D,H,P X 1.877.422.6728 http://www.campath.com/ Aldesleukin Proleukin Prometheus X X 1.877.776.5385 www.proleukin.com/mm/resources.aspx Alectinib Alecensa Genentech X X X 1.866.422.2377 www.genentech-access.com/hcp Alitretinoin Panretin Eisai X X 1.800.769.3880 www.eisaireimbursement.com Altretamine Hexalen Eisai X X 1.800.769.3880 www.eisaireimbursement.com Amifostine Ethyol D, H Aminoglutethimide Cytadren H 1.800.675.8416 www.healthwellfoundation.org Anagrelide Agrylin Shire X www.shire.com/ Anastrozole Arimidex AstraZeneca A X 1.800.292.6363 www.astrazeneca-us.com/help-affording-your-medicines Aprepitant Emend Merck X X D, H X 1.855.257.3932 www.merckaccessprogram.com/hcp/emend-capsules/ ARA-C Cytosar-U H 1.800.675.8416 www.healthwellfoundation.org Arsenic trioxide Trisenox Teva Pharmaceuticals X P X 1.888.587.3263 www.tevacares.org Asparaginase Elspar Merck D, H ATRA Vesanoid Roche X www.roche.com/index.htm Axitinib Inlyta Pfizer X X D, P X 1.866.706.2400 www.pfizerrxpathways.com Azacitidine Vidaza Teva Pharmaceuticals X D,H,P X 1.800.931.8691 www.celgenepatientsupport.com BCG TheraCys Sanofi X 1.888.847.4877 www.visitspconline.com Bendamustine Treanda Teva Pharmaceuticals X H,P,A,F X 1.888.587.3263 www.tevacares.org Bendamustine hydrochloride Bendeka Teva Pharmaceuticals X X X 1.888.587.3263 www.tevacares.org Bexarotene Targretin Eisai X P X 1.888.479.6337 www.targretin.com Bevacizumab Avastin Genentech X X D,H,P X 1.866.422.2377 www.genentech-access.com/hcp Bicalutamide Casodex AstraZeneca D, R,U X 1.800.292.6363 www.astrazeneca-us.com/help-affording-your-medicines Blenostat Beleodaq Spectrum Pharmaceticals X X X 1.866.930.1562 www.spectrumpatientaccess.com Bleomycin Blenoxane H 1.800.675.8416 www.healthwellfoundation.org Blinatumomab Blincyto Amgen X X X 1.855.669.9360 www.onyx360.com Bortezomib Velcade Millennium X D,H,P X 1.866.835.2233 www.velcade.com/payingfortreatment.aspx Bosutinib Bosulif Pfizer X X D, P X 1.866.706.2400 www.pfizerrxpathways.com Brentuximab vedotin Adcetris Seattle Genetics X X P X 1.855.473.2436 www.seagensecure.com/home/patient-assistance/ patient-assistance.html C225 Erbitux Bristol-Myers Squibb X D,H,P X 1.800.861.0048 http://www.bmsaccesssupport.bmscustomerconnect.com /oncology/services/patient-financial-assistance Cabazitaxel Jevtana Sanofi X X X 1.888.847.4877 visitspconline.com Cabozantinib Cometriq Exelixis P 1.866.316.7263 https://www.panapply.org/Application/Step1 Capecitabine Xeloda Genentech X X D,H,P X 1.866.422.2377 www.genentech-access.com/hcp Carboplatin Paraplatin H 1.800.675.8416 www.healthwellfoundation.org Carfilzomib Kyprolis Amgen X X P X 1.855.669.9360 www.onyx360.com Carmustine BiCNU Bristol-Myers Squibb X D, H X 1.800.736.0003 www.bmspaf.org Ceritinib Zykadia Novartis X H,P,F X 1.800.245.5356 www.patientassistancenow.com Cetuximab Erbitux Bristol-Myers Squibb X D,H,P X 1.800.861.0048 www.bmsaccesssupport.bmscustomerconnect.com/oncology/ services/patient-financial-assistance Chlorambucil Leukeran X P 1.866.316.7263 https://www.panapply.org/Application/Step1 Cinacalcet Sensipar Amgen X X X 1.888.427.7487 AmgenAssistOnline.com Cisplatin Platinol H 1.800.675.8416 www.healthwellfoundation.org Cisplatin Platinol-AQ H 1.800.675.8416 www.healthwellfoundation.org Cladribine Leustatin D, H Clofarabine Clolar Genzyme X X 1.888.847.4877 www.clolar.com/Hcp-financial-assistance-information Cobimetinib Cotellic Genentech X X H, P X 1.866.422.2377 www.genentech-access.com/hcp

18 / ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org TABLE OF CONTENTS

H = www.healthwellfoundation.org F = www.patientadvocate.org P = https://www.panapply.org/Application/Step1 D = http://diplomat.is/patient-support/ A = www.pparx.org IV & U = www.xubex.com INJECTABLE M = www.rxoutreach.org ORAL DRUGS O = http://rarediseases.org/for-patients-and-families/ PRESCRIPTION ONGOING X = website link has coupons SAVINGS AND/OR AND/OR FREE REPLACEMENT NO DRUG PHONE MEDICATION PROGRAM ASSISTANCE NUMBER WEBSITE 13-cis-Retinoic Acid Accutane X 2-CdA Leustatin D, H 2-Chlorodeoxyadenosine Leustatin D, H 5-Azacitidine Vidaza Celgene X D,H,P X 1.800.931.8691 www.celgenepatientsupport.com 5FU Adrucil D, H 6-Mercaptopurine Purinethol H X 1.800.675.8416 www.healthwellfoundation.org 6-MP Purinethol H X 1.800.675.8416 www.healthwellfoundation.org 6-TG Thioguanine Tab X X 1.855.382.1280 https://rebates.com/thioguanine-coupon/ 6-Thioguanine Thioguanine Tab X X 1.855.382.1280 https://rebates.com/thioguanine-coupon/ Abiraterone acetate Zytiga Janssen Biotech X X 1.855.998.4421 http://www.janssenaccessone.com/pages/zytiga/index.jsp Ado-trastuzumab emtansine Kadcyla Genentech X X D,H,P X 1.866.422.2377 www.genentech-access.com/hcp Afatinib Gilotrif Tablets Boehringer Ingelheim X P 1.877.814.3915 https://www.gilotrif.com/solutions_plus.html Alemtuzumab Campath Genzyme X D,H,P X 1.877.422.6728 http://www.campath.com/ Aldesleukin Proleukin Prometheus X X 1.877.776.5385 www.proleukin.com/mm/resources.aspx Alectinib Alecensa Genentech X X X 1.866.422.2377 www.genentech-access.com/hcp Alitretinoin Panretin Eisai X X 1.800.769.3880 www.eisaireimbursement.com Altretamine Hexalen Eisai X X 1.800.769.3880 www.eisaireimbursement.com Amifostine Ethyol D, H Aminoglutethimide Cytadren H 1.800.675.8416 www.healthwellfoundation.org Anagrelide Agrylin Shire X www.shire.com/ Anastrozole Arimidex AstraZeneca A X 1.800.292.6363 www.astrazeneca-us.com/help-affording-your-medicines Aprepitant Emend Merck X X D, H X 1.855.257.3932 www.merckaccessprogram.com/hcp/emend-capsules/ ARA-C Cytosar-U H 1.800.675.8416 www.healthwellfoundation.org Arsenic trioxide Trisenox Teva Pharmaceuticals X P X 1.888.587.3263 www.tevacares.org Asparaginase Elspar Merck D, H ATRA Vesanoid Roche X www.roche.com/index.htm Axitinib Inlyta Pfizer X X D, P X 1.866.706.2400 www.pfizerrxpathways.com Azacitidine Vidaza Teva Pharmaceuticals X D,H,P X 1.800.931.8691 www.celgenepatientsupport.com BCG TheraCys Sanofi X 1.888.847.4877 www.visitspconline.com Bendamustine Treanda Teva Pharmaceuticals X H,P,A,F X 1.888.587.3263 www.tevacares.org Bendamustine hydrochloride Bendeka Teva Pharmaceuticals X X X 1.888.587.3263 www.tevacares.org Bexarotene Targretin Eisai X P X 1.888.479.6337 www.targretin.com Bevacizumab Avastin Genentech X X D,H,P X 1.866.422.2377 www.genentech-access.com/hcp Bicalutamide Casodex AstraZeneca D, R,U X 1.800.292.6363 www.astrazeneca-us.com/help-affording-your-medicines Blenostat Beleodaq Spectrum Pharmaceticals X X X 1.866.930.1562 www.spectrumpatientaccess.com Bleomycin Blenoxane H 1.800.675.8416 www.healthwellfoundation.org Blinatumomab Blincyto Amgen X X X 1.855.669.9360 www.onyx360.com Bortezomib Velcade Millennium X D,H,P X 1.866.835.2233 www.velcade.com/payingfortreatment.aspx Bosutinib Bosulif Pfizer X X D, P X 1.866.706.2400 www.pfizerrxpathways.com Brentuximab vedotin Adcetris Seattle Genetics X X P X 1.855.473.2436 www.seagensecure.com/home/patient-assistance/ patient-assistance.html C225 Erbitux Bristol-Myers Squibb X D,H,P X 1.800.861.0048 http://www.bmsaccesssupport.bmscustomerconnect.com /oncology/services/patient-financial-assistance Cabazitaxel Jevtana Sanofi X X X 1.888.847.4877 visitspconline.com Cabozantinib Cometriq Exelixis P 1.866.316.7263 https://www.panapply.org/Application/Step1 Capecitabine Xeloda Genentech X X D,H,P X 1.866.422.2377 www.genentech-access.com/hcp Carboplatin Paraplatin H 1.800.675.8416 www.healthwellfoundation.org Carfilzomib Kyprolis Amgen X X P X 1.855.669.9360 www.onyx360.com Carmustine BiCNU Bristol-Myers Squibb X D, H X 1.800.736.0003 www.bmspaf.org Ceritinib Zykadia Novartis X H,P,F X 1.800.245.5356 www.patientassistancenow.com Cetuximab Erbitux Bristol-Myers Squibb X D,H,P X 1.800.861.0048 www.bmsaccesssupport.bmscustomerconnect.com/oncology/ services/patient-financial-assistance Chlorambucil Leukeran X P 1.866.316.7263 https://www.panapply.org/Application/Step1 Cinacalcet Sensipar Amgen X X X 1.888.427.7487 AmgenAssistOnline.com Cisplatin Platinol H 1.800.675.8416 www.healthwellfoundation.org Cisplatin Platinol-AQ H 1.800.675.8416 www.healthwellfoundation.org Cladribine Leustatin D, H Clofarabine Clolar Genzyme X X 1.888.847.4877 www.clolar.com/Hcp-financial-assistance-information Cobimetinib Cotellic Genentech X X H, P X 1.866.422.2377 www.genentech-access.com/hcp

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PAP /quick reference guide

BENEFIT VERIFICATION AND DRUG COMPANY AUTHORIZATION CO-PAY FOUNDATION DRUG NAME BRAND NAME DRUG COMPANY SUPPORT ASSISTANCE ASSISTANCE CPT-11 Camptosar Pfizer X D,H,P X 1.866.706.2400 www.pfizerrxpathways.com Crizotinib Xalkori Pfizer X X 1.866.706.2400 www.pfizerrxpathways.com Cyclophosphamide Cytoxan H 1.800.675.8416 www.healthwellfoundation.org Cyclophosphamide Neosar H 1.800.675.8416 www.healthwellfoundation.org Cytarabine Cytosar-U H 1.800.675.8416 www.healthwellfoundation.org Dabrafenib Tafinlar Novartis X H,A,F,P X X 1.800.282.7630 hcp.novartis.com/access Dactinomycin Cosmegen Recordati Rare Diseases D, H X Dacarbazine DTIC H 1.800.675.8416 www.healthwellfoundation.org Daratumumab Darzalex Janssen Biotech, Inc X X H, P X 1.844.553.2792 www.janssenaccessone.com/pages/darzalex/index.jsp Darbepoetin Aranesp Amgen X H,P,F X 1.888.427.7478 www.AmgenAssistOnline.com Dasatinib Sprycel Bristol-Myers Squibb X X 1.800.861.0048 www.bmsaccesssupport.bmscustomerconnect.com/oncology/ services/patient-financial-assistance Daunorubicin Cerubidine X Decitabine Dacogen Otsuka America H, P 1.866.316.7263 https://www.panapply.org/Application/Step1 Deferasirox Exjade Novartis X X X 1.800.245.5356 www.patientassistancenow.com Deferasirox Jadenu Novartis X X X X 1.800.245.5356 patientassistancenow.com Degarelix Firmagon Ferring X P 1.877.971.3778 www.firmagononline.com Denileukin diftitox Ontak Eisai X X 1.866.613.4724 Denosumab Prolia Amgen X X H,P,F X 1.888.427.7487 www.AmgenAssistOnline.com Denosumab Xgeva Amgen X X H,P,F X 1.888.427.7487 www.AmgenAssistOnline.com Dexrazoxane Zinecard Pfizer X X X 1.866.706.2400 www.pfizerrxpathways.com Dinutuximab Unituxin United Therapeutics Corp P www.unither.com/ Docetaxel Taxotere Sanofi D,H,P X 1.866.316.7263 https://www.panapply.org/Application/Step1 Doxorubicin Adriamycin H 1.800.675.8416 www.healthwellfoundation.org Doxorubicin Liposome Doxil Janssen Biotech, Inc X D,H,P X 1.800.609.1083 www.doxiline.com/pages/doxil/call-center/introduction.jsp Elotuzumab Empliciti Bristol-Myers Squibb X X 1.800.861.0048 http://www.bmsaccesssupport.bmscustomerconnect.com/oncology/ services/patient-financial-assistance Eltrombopag Promacta Novartis X X H,A,F,P X 1.800.245.5356 www.patientassistancenow.com Enzalutamide Xtandi Medivation X D, P X 1.855.898.2634 astellaspharmasupportsolutions.com Epirubicin Ellence Pfizer X D, H X 1.866.706.2400 www.pfizerrxpathways.com Epoetin alpha Epogen Amgen X X X 1.888.427.7487 AmgenAssistOnline.com Epoetin alpha Procrit Janssen Biotech, Inc X D, H X 1.800.553.3851 www.janssenprescriptionassistance.com/procrit-cost-assistance Eribulin mesylate Halaven Eisai X P X 1.866.614.4724 www.eisaipatientassistance.com Erlotinib Tarceva Genentech X X H, P X 1.866.422.2377 www.genentech-access.com/hcp Erwinia Asparaginase Elspar D, H Estramustine Emcyt Pfizer X X P X 1.866.706.2400 www.pfizerrxpathways.com Etoposide VePesid H 1.800.675.8416 www.healthwellfoundation.org Etoposide Toposar H 1.800.675.8416 www.healthwellfoundation.org Everolimus Afinitor Novartis X D, P X 1.800.245.5356 www.patientassistancenow.com Exemestane Aromasin Pfizer X X H,P,U X 1.866.706.2400 www.pfizerrxpathways.com Filgrastim Neupogen Amgen X D,H,P X 1.888.762.6436 www.AmgenAssistOnline.com Filgrastim-sndz Zarxio Sandoz X X X 1.844.726.3691 www.sandozonesource.com Finasteride Proscar Merck M 1.800.769.3800 www.rxoutreach.org Flourouracil 5FU D, H Floxuridine FUDR H 1.800.675.8416 www.healthwellfoundation.org Fludarabine Fludara H, P Fluoxymesterone Halotestin H 1.800.675.8416 www.healthwellfoundation.org Flutamide Eulexin H, P Fosaprepitant Emend Merck X X D, H X 1.855.257.3932 www.merckaccessprogram.com Fulvestrant Faslodex AstraZeneca D,H,P X 1.800.292.6363 www.astrazeneca-us.com/help-affording-your-medicines Gefitinib Iressa AstraZeneca H, P X 1.800.292.6363 www.astrazeneca-us.com/help-affording-your-medicines Gemcitibine Gemzar Eli Lilly D,H,P X 1.866.472.8663 www.lillytruassist.com/aboutpatientone.aspx#Drugs Gemtuzumab Ozogamicin Mylotarg Pfizer X X H,P,U X 1.866.706.2400 www.pfizerrxpathways.com Goserlin Zoladex AstraZeneca D,H,P X 1.800.292.6363 www.astrazeneca-us.com/help-affording-your-medicines Granisetron Transdermal Sancuso ProStraken X X D X X 1.800.676.5884 www.patientrxsolutions.com Hydroxyurea Hydrea H,U,M Ibritumomab Tiuxetin Zevalin Spectrum Pharmaceuticals X X 1.888.537.8277 www.spectrumpatientaccess.com/ Ibrutinib Imbruvica Pharmacyclics X X X 1.877.877.3536 www.imbruvica.com/youandi Idarubicin Idamycin Pfizer X X X 1.866.706.2400 www.pfizerrxpathways.com

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H = www.healthwellfoundation.org F = www.patientadvocate.org P = https://www.panapply.org/Application/Step1 D = http://diplomat.is/patient-support/ A = www.pparx.org IV & U = www.xubex.com INJECTABLE M = www.rxoutreach.org ORAL DRUGS O = http://rarediseases.org/for-patients-and-families/ PRESCRIPTION ONGOING X = website link has coupons SAVINGS AND/OR AND/OR FREE REPLACEMENT NO DRUG PHONE MEDICATION PROGRAM ASSISTANCE NUMBER WEBSITE CPT-11 Camptosar Pfizer X D,H,P X 1.866.706.2400 www.pfizerrxpathways.com Crizotinib Xalkori Pfizer X X 1.866.706.2400 www.pfizerrxpathways.com Cyclophosphamide Cytoxan H 1.800.675.8416 www.healthwellfoundation.org Cyclophosphamide Neosar H 1.800.675.8416 www.healthwellfoundation.org Cytarabine Cytosar-U H 1.800.675.8416 www.healthwellfoundation.org Dabrafenib Tafinlar Novartis X H,A,F,P X X 1.800.282.7630 hcp.novartis.com/access Dactinomycin Cosmegen Recordati Rare Diseases D, H X Dacarbazine DTIC H 1.800.675.8416 www.healthwellfoundation.org Daratumumab Darzalex Janssen Biotech, Inc X X H, P X 1.844.553.2792 www.janssenaccessone.com/pages/darzalex/index.jsp Darbepoetin Aranesp Amgen X H,P,F X 1.888.427.7478 www.AmgenAssistOnline.com Dasatinib Sprycel Bristol-Myers Squibb X X 1.800.861.0048 www.bmsaccesssupport.bmscustomerconnect.com/oncology/ services/patient-financial-assistance Daunorubicin Cerubidine X Decitabine Dacogen Otsuka America H, P 1.866.316.7263 https://www.panapply.org/Application/Step1 Deferasirox Exjade Novartis X X X 1.800.245.5356 www.patientassistancenow.com Deferasirox Jadenu Novartis X X X X 1.800.245.5356 patientassistancenow.com Degarelix Firmagon Ferring X P 1.877.971.3778 www.firmagononline.com Denileukin diftitox Ontak Eisai X X 1.866.613.4724 Denosumab Prolia Amgen X X H,P,F X 1.888.427.7487 www.AmgenAssistOnline.com Denosumab Xgeva Amgen X X H,P,F X 1.888.427.7487 www.AmgenAssistOnline.com Dexrazoxane Zinecard Pfizer X X X 1.866.706.2400 www.pfizerrxpathways.com Dinutuximab Unituxin United Therapeutics Corp P www.unither.com/ Docetaxel Taxotere Sanofi D,H,P X 1.866.316.7263 https://www.panapply.org/Application/Step1 Doxorubicin Adriamycin H 1.800.675.8416 www.healthwellfoundation.org Doxorubicin Liposome Doxil Janssen Biotech, Inc X D,H,P X 1.800.609.1083 www.doxiline.com/pages/doxil/call-center/introduction.jsp Elotuzumab Empliciti Bristol-Myers Squibb X X 1.800.861.0048 http://www.bmsaccesssupport.bmscustomerconnect.com/oncology/ services/patient-financial-assistance Eltrombopag Promacta Novartis X X H,A,F,P X 1.800.245.5356 www.patientassistancenow.com Enzalutamide Xtandi Medivation X D, P X 1.855.898.2634 astellaspharmasupportsolutions.com Epirubicin Ellence Pfizer X D, H X 1.866.706.2400 www.pfizerrxpathways.com Epoetin alpha Epogen Amgen X X X 1.888.427.7487 AmgenAssistOnline.com Epoetin alpha Procrit Janssen Biotech, Inc X D, H X 1.800.553.3851 www.janssenprescriptionassistance.com/procrit-cost-assistance Eribulin mesylate Halaven Eisai X P X 1.866.614.4724 www.eisaipatientassistance.com Erlotinib Tarceva Genentech X X H, P X 1.866.422.2377 www.genentech-access.com/hcp Erwinia Asparaginase Elspar D, H Estramustine Emcyt Pfizer X X P X 1.866.706.2400 www.pfizerrxpathways.com Etoposide VePesid H 1.800.675.8416 www.healthwellfoundation.org Etoposide Toposar H 1.800.675.8416 www.healthwellfoundation.org Everolimus Afinitor Novartis X D, P X 1.800.245.5356 www.patientassistancenow.com Exemestane Aromasin Pfizer X X H,P,U X 1.866.706.2400 www.pfizerrxpathways.com Filgrastim Neupogen Amgen X D,H,P X 1.888.762.6436 www.AmgenAssistOnline.com Filgrastim-sndz Zarxio Sandoz X X X 1.844.726.3691 www.sandozonesource.com Finasteride Proscar Merck M 1.800.769.3800 www.rxoutreach.org Flourouracil 5FU D, H Floxuridine FUDR H 1.800.675.8416 www.healthwellfoundation.org Fludarabine Fludara H, P Fluoxymesterone Halotestin H 1.800.675.8416 www.healthwellfoundation.org Flutamide Eulexin H, P Fosaprepitant Emend Merck X X D, H X 1.855.257.3932 www.merckaccessprogram.com Fulvestrant Faslodex AstraZeneca D,H,P X 1.800.292.6363 www.astrazeneca-us.com/help-affording-your-medicines Gefitinib Iressa AstraZeneca H, P X 1.800.292.6363 www.astrazeneca-us.com/help-affording-your-medicines Gemcitibine Gemzar Eli Lilly D,H,P X 1.866.472.8663 www.lillytruassist.com/aboutpatientone.aspx#Drugs Gemtuzumab Ozogamicin Mylotarg Pfizer X X H,P,U X 1.866.706.2400 www.pfizerrxpathways.com Goserlin Zoladex AstraZeneca D,H,P X 1.800.292.6363 www.astrazeneca-us.com/help-affording-your-medicines Granisetron Transdermal Sancuso ProStraken X X D X X 1.800.676.5884 www.patientrxsolutions.com Hydroxyurea Hydrea H,U,M Ibritumomab Tiuxetin Zevalin Spectrum Pharmaceuticals X X 1.888.537.8277 www.spectrumpatientaccess.com/ Ibrutinib Imbruvica Pharmacyclics X X X 1.877.877.3536 www.imbruvica.com/youandi Idarubicin Idamycin Pfizer X X X 1.866.706.2400 www.pfizerrxpathways.com

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PAP /quick reference guide

BENEFIT VERIFICATION AND DRUG COMPANY AUTHORIZATION CO-PAY FOUNDATION DRUG NAME BRAND NAME DRUG COMPANY SUPPORT ASSISTANCE ASSISTANCE Idarucizumab Praxbind Boehringer Ingelheim Idelalisib Zydelig GileadSciences, Inc X 1.844.622.2377 www.zydeligaccessconnect.com/hcp/afford/patient-assistance-program Ifosfamide Ifex H 1.800.675.8416 www.healthwellfoundation.org Imatinib Gleevec Novartis X D,H,P,F X 1.800.245.5356 www.patientassistancenow.com Interferon alfa-2a Interferon H 1.800.675.8416 www.healthwellfoundation.org Interferon alfa-2b Intron A Merck X H, P X 1.855.257.3932 www.merckaccessprogram.com/hcp/ Interleukin-2 Proleukin Prometheus X X 1.877.776.5385 www.proleukin.com/mm/resources.aspx Interleukin-11 Neumega Pfizer X X X 1.866.706.2400 www.pfizerrxpathways.com Ipilimumab Yervoy Bristol-Myers Squibb X X H, P X 1.800.861.0048 www.bmsaccesssupport.bmscustomerconnect.com/oncology/ services/patient-financial-assistance Irinotecan Camptosar Pfizer X X X 1.866.706.2400 www.pfizerrxpathways.com Irinotecan Liposome ONIVYDE Merrimack Pharm X X H, P X 1.844.664.8933 www.onivyde.com/onivyde-access-services/ Isotretinoin Accutane X Ixabepilone Ixempra Bristol-Myers Squibb D, P X 1.800.861.0048 www.bmsaccesssupport.bmscustomerconnect.com/oncology/ services/patient-financial-assistance Ixazomib Ninlaro Millennium X X X 1.844.617.6468 www.ninlaro.com/1point Lanreotide Somatuline Depot Ipsen Pharma X X P X 1.866.435.5677 www.ipsencares.com/ Lapatinib Tykerb Novartis X X D, P X 1.800.245.5356 www.patientassistancenow.com Lenalidomide Revlimid Celgene X X D,H,P X 1.800.931.8691 www.celgenepatientsupport.com Lenvatinib Lenvima Eisai X X X 1.855.347.2448 www.lenvimareimbursement.com Letrozole Femara Novartis X H,P,F X 1.800.245.5356 www.patientassistancenow.com Leucovorin Folinic Acid H 1.800.675.8416 www.healthwellfoundation.org Leuprolide Eligard Sanofi X D, H X 1.888.847.4877 www.visitspconline.com Leuprolide Acetate Lupron AbbVie D, P X 1.800.222.6885 www.abbviepaf.org/ Leuprolide Viadur D, P Mechlorethamine Mustargen Recordati Rare Diseases Megastrol Megace H 1.800.675.8416 www.healthwellfoundation.org Mephalan Alkeran D, H Mercaptopurine Purixan NOVA Lab Limited Mesna Mesnex H 1.800.675.8416 www.healthwellfoundation.org Methotrexate Folex H,U,M Methotrexate Rheumatrex H,U,M Methotrexate Trexall H,U,M Mitomycin Mutamycin D,H,P Mitoxantrone Novantrone D,H,P Necitumab Portrazza Eli Lilly and Company X X X 1.855.559.8783 www.lillypatientone.com Nelarabine Arranon Novartis 1.800.245.5356 hcp.novartis.com/access Netupitant/Palonsetron Akynzeo Eisai X X 1.855.347.2448 www.akynzeosavingsprogram.com/ Nilotinib Tasigna Novartis X X 1.800.282.7630 hcp.novartis.com/access Nilutamide Nilandron Sanofi P X 1.888.847.4877 www.visitspconline.com Nivolumab Opdivo Bristol-Myers Squibb X X X 1.800.861.0048 www.bmsaccesssupport.bmscustomerconnect.com/oncology/ services/patient-financial-assistance Obinutuzumab Gavyza Genentech X X D,H,P X 1.866.422.2377 www.genentech-access.com/hcp Octreotide Acetate Sandostatin LAR Novartis X X 1‑800‑282‑7630 hcp.novartis.com/access Ofatumumab Arzerra Novartis X X 1‑800‑282‑7630 hcp.novartis.com/access Olaparib Lynparza AstraZeneca X X X 1.844.275.2360 www.astrazeneca-us.com/medicines/help-affording-your-medicines Omacetaxine Mepesuccinate Synribo Teva Pharmaceuticals X D, P X X 1.888.587.3263 www.cephalononcologycore.com Oprelvekin Neumega Pfizer X X H,P,F X 1.866.706.2400 www.pfizerrxpathways.com Osimertinib Tagrisso AstraZeneca X X X 1.844.275.2360 www.myaccess360.com/hcp/patient-access-programs/oncology.aspx Oxaliplatin Eloxatin Sanofi X D,H,P X 1.888.847.4877 www.visitspconline.com Paclitaxel Onxal D, H Paclitaxel Taxol D,H,A Paclitaxel protein-bound Abraxane Celgene X D,H,P,F X 1.800.931.8691 www.celgenepatientsupport.com Palbociclib Ibrance Pfizer X X X 1.866.706.2400 pfizerrxpathways.com/ Palonsetron Aloxi Eisai X X 1.866.613.4724 www.eisaipatientassistance.com Pamidronate Aredia Novartis X 1.800.245.5356 www.patientassistancenow.com/ Panitumumab Vectibix Amgen X D,H.P X 1.888.762.6436 www.AmgenAssistOnline.com Panobinostat Farydak Novartis X X X 1.800.245.5356 www.hcp.novartis.com/access

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H = www.healthwellfoundation.org F = www.patientadvocate.org P = https://www.panapply.org/Application/Step1 D = http://diplomat.is/patient-support/ A = www.pparx.org U = www.xubex.com IV & M = www.rxoutreach.org INJECTABLE O = http://rarediseases.org/for-patients-and-families/ ORAL DRUGS X = website link has coupons PRESCRIPTION ONGOING SAVINGS AND/OR AND/OR FREE REPLACEMENT NO DRUG PHONE MEDICATION PROGRAM ASSISTANCE NUMBER WEBSITE Idarucizumab Praxbind Boehringer Ingelheim Idelalisib Zydelig GileadSciences, Inc X 1.844.622.2377 www.zydeligaccessconnect.com/hcp/afford/patient-assistance-program Ifosfamide Ifex H 1.800.675.8416 www.healthwellfoundation.org Imatinib Gleevec Novartis X D,H,P,F X 1.800.245.5356 www.patientassistancenow.com Interferon alfa-2a Interferon H 1.800.675.8416 www.healthwellfoundation.org Interferon alfa-2b Intron A Merck X H, P X 1.855.257.3932 www.merckaccessprogram.com/hcp/ Interleukin-2 Proleukin Prometheus X X 1.877.776.5385 www.proleukin.com/mm/resources.aspx Interleukin-11 Neumega Pfizer X X X 1.866.706.2400 www.pfizerrxpathways.com Ipilimumab Yervoy Bristol-Myers Squibb X X H, P X 1.800.861.0048 www.bmsaccesssupport.bmscustomerconnect.com/oncology/ services/patient-financial-assistance Irinotecan Camptosar Pfizer X X X 1.866.706.2400 www.pfizerrxpathways.com Irinotecan Liposome ONIVYDE Merrimack Pharm X X H, P X 1.844.664.8933 www.onivyde.com/onivyde-access-services/ Isotretinoin Accutane X Ixabepilone Ixempra Bristol-Myers Squibb D, P X 1.800.861.0048 www.bmsaccesssupport.bmscustomerconnect.com/oncology/ services/patient-financial-assistance Ixazomib Ninlaro Millennium X X X 1.844.617.6468 www.ninlaro.com/1point Lanreotide Somatuline Depot Ipsen Pharma X X P X 1.866.435.5677 www.ipsencares.com/ Lapatinib Tykerb Novartis X X D, P X 1.800.245.5356 www.patientassistancenow.com Lenalidomide Revlimid Celgene X X D,H,P X 1.800.931.8691 www.celgenepatientsupport.com Lenvatinib Lenvima Eisai X X X 1.855.347.2448 www.lenvimareimbursement.com Letrozole Femara Novartis X H,P,F X 1.800.245.5356 www.patientassistancenow.com Leucovorin Folinic Acid H 1.800.675.8416 www.healthwellfoundation.org Leuprolide Eligard Sanofi X D, H X 1.888.847.4877 www.visitspconline.com Leuprolide Acetate Lupron AbbVie D, P X 1.800.222.6885 www.abbviepaf.org/ Leuprolide Viadur D, P Mechlorethamine Mustargen Recordati Rare Diseases Megastrol Megace H 1.800.675.8416 www.healthwellfoundation.org Mephalan Alkeran D, H Mercaptopurine Purixan NOVA Lab Limited Mesna Mesnex H 1.800.675.8416 www.healthwellfoundation.org Methotrexate Folex H,U,M Methotrexate Rheumatrex H,U,M Methotrexate Trexall H,U,M Mitomycin Mutamycin D,H,P Mitoxantrone Novantrone D,H,P Necitumab Portrazza Eli Lilly and Company X X X 1.855.559.8783 www.lillypatientone.com Nelarabine Arranon Novartis 1.800.245.5356 hcp.novartis.com/access Netupitant/Palonsetron Akynzeo Eisai X X 1.855.347.2448 www.akynzeosavingsprogram.com/ Nilotinib Tasigna Novartis X X 1.800.282.7630 hcp.novartis.com/access Nilutamide Nilandron Sanofi P X 1.888.847.4877 www.visitspconline.com Nivolumab Opdivo Bristol-Myers Squibb X X X 1.800.861.0048 www.bmsaccesssupport.bmscustomerconnect.com/oncology/ services/patient-financial-assistance Obinutuzumab Gavyza Genentech X X D,H,P X 1.866.422.2377 www.genentech-access.com/hcp Octreotide Acetate Sandostatin LAR Novartis X X 1‑800‑282‑7630 hcp.novartis.com/access Ofatumumab Arzerra Novartis X X 1‑800‑282‑7630 hcp.novartis.com/access Olaparib Lynparza AstraZeneca X X X 1.844.275.2360 www.astrazeneca-us.com/medicines/help-affording-your-medicines Omacetaxine Mepesuccinate Synribo Teva Pharmaceuticals X D, P X X 1.888.587.3263 www.cephalononcologycore.com Oprelvekin Neumega Pfizer X X H,P,F X 1.866.706.2400 www.pfizerrxpathways.com Osimertinib Tagrisso AstraZeneca X X X 1.844.275.2360 www.myaccess360.com/hcp/patient-access-programs/oncology.aspx Oxaliplatin Eloxatin Sanofi X D,H,P X 1.888.847.4877 www.visitspconline.com Paclitaxel Onxal D, H Paclitaxel Taxol D,H,A Paclitaxel protein-bound Abraxane Celgene X D,H,P,F X 1.800.931.8691 www.celgenepatientsupport.com Palbociclib Ibrance Pfizer X X X 1.866.706.2400 pfizerrxpathways.com/ Palonsetron Aloxi Eisai X X 1.866.613.4724 www.eisaipatientassistance.com Pamidronate Aredia Novartis X 1.800.245.5356 www.patientassistancenow.com/ Panitumumab Vectibix Amgen X D,H.P X 1.888.762.6436 www.AmgenAssistOnline.com Panobinostat Farydak Novartis X X X 1.800.245.5356 www.hcp.novartis.com/access

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 23 TABLE OF CONTENTS

PAP /quick reference guide

BENEFIT VERIFICATION AND DRUG COMPANY AUTHORIZATION CO-PAY FOUNDATION DRUG NAME BRAND NAME DRUG COMPANY SUPPORT ASSISTANCE ASSISTANCE Pazopanib Votrient Novartis X X P X 1.800.245.5356 www.oncologyaccessnow.com/index.jsp Pegaspargase Oncaspar Baxalta Pegfilgrastim Neulasta Amgen X X D, H X 1.888.427.7478 www.AmgenAssistOnline.com Peginterferon Alfa-2b Sylatron Merck X X D, H X 1.855.257.3932 www.merckaccessprogram.com/ Pembrolizumab Keytruda Merck X X D,H X 1.855.257.3932 www.merckaccessprogram-keytruda.com Pemetrexed Alimta Eli Lilly D,H,P X 1.866.472.8663 www.lillypatientone.com Pentostatin Nipent Hospira X Pertuzumab Perjeta Genentech X X D,H,P X 1.866.422.2377 www.genentech-access.com/hcp Plerixafor Mozobil Genzyme X D, P X 1.877.466.9624 www.mozobil.com/healthcare/billing_and_reimbursement.asp Pomalidomide Pomalyst Celgene X D,H,P,F X 1.800.931.8691 www.celgenepatientsupport.com Ponatinib Iclusig Ariad Pharmaceuticals X X D X 1.855.447.7277 ariadpass.com/hcp.html Pralatrexate Folotyn Spectrum Pharmaceuticals X O X 1.888.537.8277 www.folotyn.com/HCP/star-program.aspx Radium RA 223 Dichloride Xofigo Bayer HealthCare X X X 1.855.696.3446 hcp.xofigo-us.com/patient-financial-assistance Ramucircumab Cyramza Eli Lilly and Company X X D,H,P X 1.866.472.8663 www.lillypatientone.com Rasburicase Elitek Sanofi X H,P,F,O X 1.888.847.4877 www.visitspconline.com Regorafenib Stivarga Bayer HealthCare X X 1.866.639.2827 www.stivarga-us.com/how_to_access_stivarga.html Rituximab Rituxan Genentech X X D,H,P X 1.866.422.2377 www.genentech-access.com/hcp Romidepsin Istodax Celgene X P X 1.800.931.8691 www.celgenepatientsupport.com Romiplostim Nplate Amgen X X H,P,F X 1.888.427.7478 www.AmgenAssistOnline.com Ruxolitninib Jakafi Incyte X X D, P X 1.855.452.5234 www.incytecares.com Sargramostim Leukine Genzyme X H X 1.888.847.4877 www.visitspconline.com/ Sipuleucel-t Provenge Dendreon X P X 1.877.336.3736 www.provenge.com/reimbursement.aspx Siltuximab Sylvant Janssen Biotech, Inc X X X 1.855.299.8844 www.janssenaccessone.com/pages/sylvant/patientassist/intro.jsp Sonidegib Odomzo Novartis X X X 1.800.277.2254 www.pharma.us.novartis.com/info/patient-assistance/patient- assistance-enrollment.jsp?brand=Odomzo Sorafenib Nexavar Bayer HealthCare X X D, P X 1.855.669.9360 www.reachpatientsupport.com Streptozocin Zanosar Teva X Sunitinib Sutent Pfizer X D, P X 1.866.706.2400 www.pfizerrxpathways.com Talimogene laherparepvec Imlygic Amgen X X X 1.888.427.7478 AmgenAssistOnline.com Tamoxifen Nolvadex H, M Temozolomide Temodar Merck D 1.800.727.5400 www.merckhelps.com/ Temsirolimus Torisel Pfizer X P X 1.866.706.2400 www.pfizerrxpathways.com Teniposide Vumon Bristol-Myers Squibb H X Thalidomide Thalomid Celgene X D,H,P X 1.800.931.8691 www.celgenepatientsupport.com Thiotepa Thioplex H 1.800.675.8416 www.healthwellfoundation.org Topotecan Oral Hycamptin Oral Novartis X X D,H,P X 1.800.282.7630 www.hcp.novartis.com/access Topotecan Hycamptin Novartis X X D,H,P X 1.800.282.7630 www.hcp.novartis.com/access Toremifene Fareston ProStrakan D,H,P X 1.800.676.5884 www.fareston.com/support.html Tositumomab Bexxar GlaxoSmithKline X H X Trabectedin Yondelis Janssen Biotech, Inc X X X 1.844.966.3354 www.janssenprescriptionassistance.com Trametinib Mekinist Novartis X D,A,F,P X X 1.800.282.7630 www.hcp.novartis.com/access Trastuzumab Herceptin Genentech X X D,H,P X 1.866.422.2377 www.genentech-access.com/hcp Tretinoin (ATRA) Vesanoid Roche P Trifluridine/Tipiracil Lonsurf Taiho Oncology, Inc X X D X 1.844.824.4648 www.taihopatientsupport.com Triptorelin Pamoate Trelstar Watson X X 1.866.754.3315 www.trelstar.com Vandetanib Caprelsa AstraZeneca X X P X 1.800.292.6363 www.astrazeneca-us.com/help-affording-your-medicines Valrubicin Valstar Endo Pharmaceuticals X Vemurafenib Zelboraf Genentech X X P X 1.866.422.2377 www.genentech-access.com/hcp Vinblastine Velban H 1.800.675.8416 www.healthwellfoundation.org Vincristine Oncovin D, H Vincristine Sulfate Liposome Marqibo Talon X Vinorelbine Navelbine PF Pharmaceuticals H 1.800.675.8416 www.healthwellfoundation.org Vismodegib Erivedge Genentech X X X X 1.866.422.2377 www.genentech-access.com/hcp Vorinostat Zolinza Merck X D, P X 1.800.727.5400 www.merckhelps.com VP-16 Etopophos Bristol-Myers Squibb H X VP-16 VePesid H 1.800.675.8416 www.healthwellfoundation.org VP-16 Toposar H 1.800.675.8416 www.healthwellfoundation.org Zidovudine Retrovir P Ziv-Aflibercept Zaltrap Sanofi X P X 1.888.847.4877 www.visitspconline.com Zoledronic acid Zometa Novartis X D, P X 1.800.245.5356 www.patientassistancenow.com

24 / ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org TABLE OF CONTENTS

H = www.healthwellfoundation.org F = www.patientadvocate.org P = https://www.panapply.org/Application/Step1 D = http://diplomat.is/patient-support/ IV & A = www.pparx.org U = www.xubex.com INJECTABLE M = www.rxoutreach.org ORAL DRUGS O = http://rarediseases.org/for-patients-and-families/ PRESCRIPTION ONGOING X = website link has coupons SAVINGS AND/OR AND/OR FREE REPLACEMENT NO DRUG PHONE MEDICATION PROGRAM ASSISTANCE NUMBER WEBSITE Pazopanib Votrient Novartis X X P X 1.800.245.5356 www.oncologyaccessnow.com/index.jsp Pegaspargase Oncaspar Baxalta Pegfilgrastim Neulasta Amgen X X D, H X 1.888.427.7478 www.AmgenAssistOnline.com Peginterferon Alfa-2b Sylatron Merck X X D, H X 1.855.257.3932 www.merckaccessprogram.com/ Pembrolizumab Keytruda Merck X X D,H X 1.855.257.3932 www.merckaccessprogram-keytruda.com Pemetrexed Alimta Eli Lilly D,H,P X 1.866.472.8663 www.lillypatientone.com Pentostatin Nipent Hospira X Pertuzumab Perjeta Genentech X X D,H,P X 1.866.422.2377 www.genentech-access.com/hcp Plerixafor Mozobil Genzyme X D, P X 1.877.466.9624 www.mozobil.com/healthcare/billing_and_reimbursement.asp Pomalidomide Pomalyst Celgene X D,H,P,F X 1.800.931.8691 www.celgenepatientsupport.com Ponatinib Iclusig Ariad Pharmaceuticals X X D X 1.855.447.7277 ariadpass.com/hcp.html Pralatrexate Folotyn Spectrum Pharmaceuticals X O X 1.888.537.8277 www.folotyn.com/HCP/star-program.aspx Radium RA 223 Dichloride Xofigo Bayer HealthCare X X X 1.855.696.3446 hcp.xofigo-us.com/patient-financial-assistance Ramucircumab Cyramza Eli Lilly and Company X X D,H,P X 1.866.472.8663 www.lillypatientone.com Rasburicase Elitek Sanofi X H,P,F,O X 1.888.847.4877 www.visitspconline.com Regorafenib Stivarga Bayer HealthCare X X 1.866.639.2827 www.stivarga-us.com/how_to_access_stivarga.html Rituximab Rituxan Genentech X X D,H,P X 1.866.422.2377 www.genentech-access.com/hcp Romidepsin Istodax Celgene X P X 1.800.931.8691 www.celgenepatientsupport.com Romiplostim Nplate Amgen X X H,P,F X 1.888.427.7478 www.AmgenAssistOnline.com Ruxolitninib Jakafi Incyte X X D, P X 1.855.452.5234 www.incytecares.com Sargramostim Leukine Genzyme X H X 1.888.847.4877 www.visitspconline.com/ Sipuleucel-t Provenge Dendreon X P X 1.877.336.3736 www.provenge.com/reimbursement.aspx Siltuximab Sylvant Janssen Biotech, Inc X X X 1.855.299.8844 www.janssenaccessone.com/pages/sylvant/patientassist/intro.jsp Sonidegib Odomzo Novartis X X X 1.800.277.2254 www.pharma.us.novartis.com/info/patient-assistance/patient- assistance-enrollment.jsp?brand=Odomzo Sorafenib Nexavar Bayer HealthCare X X D, P X 1.855.669.9360 www.reachpatientsupport.com Streptozocin Zanosar Teva X Sunitinib Sutent Pfizer X D, P X 1.866.706.2400 www.pfizerrxpathways.com Talimogene laherparepvec Imlygic Amgen X X X 1.888.427.7478 AmgenAssistOnline.com Tamoxifen Nolvadex H, M Temozolomide Temodar Merck D 1.800.727.5400 www.merckhelps.com/ Temsirolimus Torisel Pfizer X P X 1.866.706.2400 www.pfizerrxpathways.com Teniposide Vumon Bristol-Myers Squibb H X Thalidomide Thalomid Celgene X D,H,P X 1.800.931.8691 www.celgenepatientsupport.com Thiotepa Thioplex H 1.800.675.8416 www.healthwellfoundation.org Topotecan Oral Hycamptin Oral Novartis X X D,H,P X 1.800.282.7630 www.hcp.novartis.com/access Topotecan Hycamptin Novartis X X D,H,P X 1.800.282.7630 www.hcp.novartis.com/access Toremifene Fareston ProStrakan D,H,P X 1.800.676.5884 www.fareston.com/support.html Tositumomab Bexxar GlaxoSmithKline X H X Trabectedin Yondelis Janssen Biotech, Inc X X X 1.844.966.3354 www.janssenprescriptionassistance.com Trametinib Mekinist Novartis X D,A,F,P X X 1.800.282.7630 www.hcp.novartis.com/access Trastuzumab Herceptin Genentech X X D,H,P X 1.866.422.2377 www.genentech-access.com/hcp Tretinoin (ATRA) Vesanoid Roche P Trifluridine/Tipiracil Lonsurf Taiho Oncology, Inc X X D X 1.844.824.4648 www.taihopatientsupport.com Triptorelin Pamoate Trelstar Watson X X 1.866.754.3315 www.trelstar.com Vandetanib Caprelsa AstraZeneca X X P X 1.800.292.6363 www.astrazeneca-us.com/help-affording-your-medicines Valrubicin Valstar Endo Pharmaceuticals X Vemurafenib Zelboraf Genentech X X P X 1.866.422.2377 www.genentech-access.com/hcp Vinblastine Velban H 1.800.675.8416 www.healthwellfoundation.org Vincristine Oncovin D, H Vincristine Sulfate Liposome Marqibo Talon X Vinorelbine Navelbine PF Pharmaceuticals H 1.800.675.8416 www.healthwellfoundation.org Vismodegib Erivedge Genentech X X X X 1.866.422.2377 www.genentech-access.com/hcp Vorinostat Zolinza Merck X D, P X 1.800.727.5400 www.merckhelps.com VP-16 Etopophos Bristol-Myers Squibb H X VP-16 VePesid H 1.800.675.8416 www.healthwellfoundation.org VP-16 Toposar H 1.800.675.8416 www.healthwellfoundation.org Zidovudine Retrovir P Ziv-Aflibercept Zaltrap Sanofi X P X 1.888.847.4877 www.visitspconline.com Zoledronic acid Zometa Novartis X D, P X 1.800.245.5356 www.patientassistancenow.com

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 25 TABLE OF CONTENTS AbbVie

AbbVie, Inc.

Oncology-related products: Lupron Depot® (leuprolide acetate for depot suspension)

Patient and Reimbursement Assistance Website abbviepaf.org

PATIENT ASSISTANCE Submit the completed application REIMBURSEMENT by fax: 866.483.1305 or mail: ASSISTANCE AbbVie Patient AbbVie Patient Assistance Assistance Foundation Foundation, PO Box 270, Reimbursement The foundation offers a variety of Somerville, NJ 08876. Questions? Resources assistance programs to meet the Call 1.800.222.6885, Monday Providers with reimbursement needs of the specific people who through Friday, 8:00 am to questions can call the toll-free are prescribed AbbVie medications. 5:00 pm CST. reimbursement hotline at: Income eligibility criteria varies 1.800.453.8438. If you are ex- by medication and is based on the We will contact patients and periencing reimbursement issues, federal poverty guidelines, which providers about the application customer service representatives are are adjusted each year. To apply: within a week to let patients know available to assist. • Click on the medication if they are approved for assistance. (abbviepaf.org/apply.cfm). If the application was missing • Complete the application. information we will ask the patient Fill out the sections completely and/or provider to provide missing (please refer to the checklist information. Once received we on the application). will evaluate the application. We • Attach proof of income will contact patients and providers if required. about the application within a week • Be sure the patient and provider to let them know if the patient is sign and date the application. now approved for assistance. • If patient has Medicare Part D and is applying for assistance, download and complete the appropriate attestation form.

26 / ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org TABLE OF CONTENTS Amgen

Amgen, Inc.

Oncology-related products: Aranesp® (darbepoetin alfa), Blincyto® (blinatumomab), Epogen® (epoetin alfa), Imlygic™ (talimogene laherparepvec) suspension for intralesional injection, Kyprolis® (carfilzomib), Neulasta® (pegfilgrastim), Neupogen® (filgrastim), Nplate® (romiplostim), Prolia® (denosumab), Sensipar® (cinacalcet), Vectibix®, (panitumumab), Xgeva™ (denosumab)

Patient and Reimbursement Assistance Websites amgenassistonline.com onyx360.com

PATIENT ASSISTANCE covers medication costs for the Maximum benefit of $5,000 drugs listed above. per patient per 6-month calendar Co-pay Assistance • Patients must not partici- period (for Prolia: a maximum Support pate in any federal, state, or benefit of $1,500 per patient per Amgen offers co-pay coupon government-funded healthcare 6-month calendar period). Patient programs for Neulasta, Neupogen, program, such as Medicare, is responsible for costs above Nplate, Prolia, Vectibix, and Xgeva Medicare Advantage, Medicare these amounts. to help eligible patients who are Part D, Medicaid, Medigap, VA, commercially insured with their DoD, or TriCare. Restrictions may apply. Amgen deductible, co-insurance, • Patients may not seek reim- reserves the right to revise or and/or co-payment requirements. bursement for value received terminate this program, in whole To confirm patient eligibility and from the Amgen FIRST STEP or in part, without notice at any enroll in one of these programs, call Program from any third- time. This is not health insurance. 1.888.65.STEP1 (888.657.8371) party payers, including flexible Program invalid where otherwise or visit amgenfirststep.com. spending accounts or healthcare prohibited by law. Register before savings accounts. any Amgen treatment. Amgen FIRST STEP™ Program Coverage Limits Learn more at the Amgen FIRST This financial support program • Program covers out-of-pocket STEP Co-pay Card Program Health helps commercially-insured eligible medication costs for the Amgen Care Provider Portal: amgenfirst- patients with their co-pay and other product only. Program does not step.com/hcp. From the portal, treatment costs. Patient eligibility cover any other costs related healthcare providers can enroll requirements: to office visit or administration patients, review records, download • Patients must be prescribed one of the Amgen product. Other forms, and upload documents. of the drugs listed above. restrictions may apply. Questions? Call 1.888.65.STEP1 • Patients must have private com- • No out-of-pocket cost for first (1.888.657.8371) Monday through mercial health insurance that dose or cycle; $25 out-of-pocket Friday, 9:00 am to 8:00 pm EST. cost for subsequent dose or cycle.

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 27 TABLE OF CONTENTS Amgen

Uninsured Patients Foundation (safetynetfoundation. group information, nutritional Patients may be able to receive com/pdf/RE-SNF-002-P_V2_ information, side effect man- Amgen medications at no cost from Facility_Application.pdf). The agement, along with practical The Safety Net Foundation (safety facility can then submit requests matters related to the patient’s netfoundation.com/index.html) if for replacement product using the condition they meet the following eligibility Product Replacement Request Form requirements: (safetynetfoundation.com/pdf/RE- Providers can enroll their patients • Are a resident of the U.S. or SNF-012-A_Product_Replacement_ online at: onyx360.com/hcp. All its territories Order_Form.pdf). Institutions that services are subject to eligibility • Satisfy income eligibility have enrolled as Individual Patient requirements. The online form requirements Assistance Program (IPAP) facilities includes three sections, and you • Have no or limited drug may use the IPAP Patient Applica- should have the following informa- coverage tion (safetynetfoundation.com/pdf/ tion available: • Do not have any other RE-SNF-011-C_IPAP_Patient_ insurance or financial support Application_UpdatedV3.pdf) to Section 1. Patient Information options. enroll their patients. 1. Your patient’s contact information, including address and NOTE: Qualifying Medicare Part D Questions? Call 1.888.762.6436. phone number patients may also be eligible if they 2. Your professional contact meet additional criteria demonstrat- Onyx 360 information. ing inability to afford medications This comprehensive, personalized based on income. program provides information and Section 2. Free Product patient assistance for patients on Assistance To enroll in The Safety Net Foun- Blincyto and Kyprolis, including: 1. Your patient’s current annual dation, patients must meet program • Free product services. Assis- household adjusted gross eligibility requirements and tance for uninsured patients income complete the Patient Application or those rendered uninsured 2. Your patient’s federal tax Form: through payer denial who meet return, W2 form, or Social • (English) safetynetfoundation. certain income, medical, and Security benefit statement. com/pdf/RE-SNF-001-A- eligibility criteria. Application-Prescription_v6_ • Independent foundation Section 3. Insurance Information FINAL.pdf assistance. Co-pay and/or co- 1. Your patient’s insurance in- • (Spanish) safetynet insurance assistance through formation, including carrier, foundation.com/pdf/ third-party foundations. phone number, policy ID, group RE-SNF-001B-Application- • Transportation and lodging number, and subscriber’s date SpanishPrescription_v6.pdf. cost assistance. Referral to of birth. third-party organizations for To get started, complete the Patient those patients who qualify and You can also enroll patients by Application Form above. For pre- need assistance with or help phone by calling 1.855.ONYX.360 scription products, physicians must paying for gas, lodging, tolls, (1.855.669.9360), Monday through complete the Product Prescription and parking in connection with Friday, 9:00 am to 8:00 pm EST. Form (safetynetfoundation.com/ receiving therapy pdf/RE-SNF-007-A-Product • Patient and caregiver support PrescriptionForm_V1.pdf) or services. Referral to support submit an original prescription. For services for patients, families, replacement products, the facility and caregivers that provide must first enroll in The Safety Net product information, support

28 / ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 29 TABLE OF CONTENTS Amgen

REIMBURSEMENT Onyx 360 ASSISTANCE This comprehensive, personalized program provides information Amgen Assist® Online and reimbursement assistance for Amgen Assist Online gives patients patients on Blincyto and Kyprolis, and healthcare providers a single including: destination for access to online • Insurance verification. Verifying forms, and answers to coverage, patient’s insurance informa- reimbursement, and financial assis- tion and determining patient tance questions. Services include: coverage responsibility for • Insurance verification services to be provided. • Prior authorization • Appeals support. • Billing and claims processing support and tracking Providers can enroll their patients • Policy and program updates. online at: onyx360.com/hcp (see the instructions above) or Online tools include: by calling: 1.855.ONYX.360 • Benefit verification forms (1.855.669.9360), Monday through • Patient consent forms Friday, 9:00 am to 8:00 pm EST. • Sample letter of appeals • Sample letter of medical necessity.

Register today at: amgenassist online.com/Registration/ Registration.aspx. You can also call Amgen Assist at 1.888.4ASSIST (1.888.427.7478) and speak with an Amgen Reimbursement Counselor specific to your region for support with reimbursement or patient assistance. You can contact Amgen Assist by phone to request insurance verifications regarding Amgen products and for reimbursement and assistance information. Available Monday through Friday, 9:00 am to 8:00 pm EST.

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 29 TABLE OF CONTENTS ARIAD

ARIAD Pharmaceuticals, Inc.

Oncology-related products: Iclusig™ (ponatinib)

Patient and Reimbursement Assistance Website ariadpass.com

PATIENT ASSISTANCE and perform an initial baseline as- has a temporary lapse in insurance sessment. The biologics multidisci- coverage for any reason, ARIAD has ARIAD PASS™ plinary pharmacy care team will: created ARIAD Assurance PASS. To support your patients, • Counsel your patient, including The plan is designed to ensure that ARIAD has partnered with a review of drug and food in- patients who start on treatment are Biologics, Inc., an oncology teractions, dosage, and possible able to stay on treatment even if pharmacy that provides a compre- side effects there’s a change in their insurance hensive and personalized approach • Provide information on status. For ARIAD Assurance PASS, to supporting patients throughout adherence and side effect man- medication can be provided at no their prescribed therapy. Each agement support throughout cost for up to 90 days. There are of your ARIAD patients will be therapy three ways you can get your patients assigned a biologics oncology • Coordinate with your patient access to ARIAD PASS: pharmacist and nurse specialist to set up free delivery and free to provide clinical support refill delivery based on your 1. Call toll-free 1.855.447.PASS from receipt of prescription patient’s therapy schedule (1.855.447.7277) Monday throughout treatment. • Contact your office if a new through Friday, 9:00 am to 6:00 prescription is needed pm, EST Enrolling your patients in ARIAD • Advise your patients on how 2. Fax the completed ARIAD PASS PASS is easy with the ARIAD PASS to take, store, and properly Prescription Form to 1.855.557. Prescription Form (ariadpass.com/ dispose of medication. PASS (1.855.557.7277) packaged/assets/pdf/ARIAD_PASS_ 3. Visit ARIADPASS.com to Prescription_Form.pdf), which The patient access specialist download additional ARIAD can be faxed to ARIAD PASS at provides eligible patients with PASS Prescription Forms. 1.855.557.PASS (1.855.557.7277). an array of financial assistance options, including co-pay or REIMBURSEMENT A patient access specialist will co-insurance support, based on ASSISTANCE conduct a benefits investigation their insurance coverage and and provide the results. The patient financial needs. If your patient ARIAD PASS access specialist will also work with requires medication during a reim- A Patient Access Specialist quickly patients who are unable to afford bursement delay, the benefits coor- determines your patient’s level of therapy. Once a benefits inves- dinator can provide your patient insurance coverage and any addi- tigation is complete, a biologics with a one-time, 30-day supply to tional requirements, such as prior oncology pharmacist will contact ensure that they can start medica- authorizations, so your patient can your patient to schedule delivery tion free of cost. If your patient promptly begin therapy.

30 / ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 31 TABLE OF CONTENTS Astellas

Astellas Pharma US, Inc.

Oncology-related products: Tarceva® (erlotinib) tablets (co-marketed with Genentech, Inc.), Xtandi® (enzalutamide) capsules

Patient and Reimbursement Assistance Website astellaspharmasupportsolutions.com

PATIENT ASSISTANCE entirety (required fields marked • Have been prescribed Xtandi with an asterisk), including the for an FDA-approved Xtandi signatures section. (NOTE: It is indication. Support SolutionsSM critical that the enrollment form Xtandi Support Solutions is signed by both the prescrib- Xtandi Quick Start+ Program (astellaspharmasupportsolutions. ing doctor and the patient or the allows your patient to start their com/products/xtandi) provides patient’s authorized representative.) Xtandi treatment while Xtandi services to help patients and Return by fax to 1.855.892.6341. Support Solutions or a network healthcare providers with access specialty pharmacy works with and reimbursement, and informa- Xtandi Quick Start+ the patient’s insurer to resolve co- tion regarding coverage options Program verage issues. Xtandi Quick Start+ and financial assistance programs. The Xtandi Quick Start+ Program Program offers overnight shipping Xtandi Support Solutions offers: provides a free, one-time 14-day directly to your patient. Complete • Instructions for filling out supply of Xtandi to new patients the Quick Start+ section of the the Xtandi Solutions patient who experience a delay in insu- Xtandi Support Solutions Patient enrollment form rance coverage. Xtandi Support Enrollment Form (astellaspharma • Benefits verification Solutions will identify new patients supportsolutions.com/docs/xtandi/ • Prior authorization requests who may be eligible for the Quick XSS_Patient_Enrollment_Form. • Assistance with appeals when Start+ Program. If prescriptions pdf), so eligible patients can prior authorization requests are not filled within 7 business receive a Quick Start+ prescription are denied days due to insurance coverage if needed. • Xtandi Quick Start+ Program delays, Xtandi Support Solutions • Patient assistance assesses the case for eligibility. A Commercially • Specialty pharmacy 14-day supply of Xtandi is shipped Insured Patients coordination. overnight directly to the patient. The Xtandi Patient Savings Program In order to be eligible for the is for patients who have commercial To enroll your patient in Xtandi Quick Start+ program, patients and/or private health insurance Support Solutions, complete the need to: but who may have trouble paying Patient Enrollment Form • Be new to Xtandi therapy their out-of-pocket costs. Under (astellaspharmasupportsolutions. • Have experienced an this program: com/docs/xtandi/XSS_Patient_ insurance-related access delay • Patients should expect to pay no Enrollment_Form.pdf) in its more than $20 per prescription

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 31 TABLE OF CONTENTS Astellas

• Co-pay assistance is available • Patient has a verifiable shipping scription drug benefit. However, for up to 12 refills address in the United States a patient’s cost share may vary, • Your patient is covered for • Patient has been prescribed depending on their Medicare plan. savings up to $5,000 for each Xtandi for an FDA approved Xtandi Support Solutions can prescription and a maximum indication help evaluate a Medicare patient’s savings up to $12,000 per year • Patient has an annual adjusted financial need and assistance options. • There are no income gross household income of less Xtandi Support Solutions can: requirements. than $100,000 per year. • Help determine what type of cost-sharing the patient has, The program is not available to Xtandi Support Solutions can such as a flat co-payment or a patients who have prescription determine whether a patient meets percentage-based co-insurance drug coverage paid in part or in full these criteria. To enroll a patient with • Evaluate eligibility for Medicare under any state or federally funded the Astellas Access Program, com- Part D patients who may qualify programs, including but not limited plete the Patient Enrollment Form for the Low-Income Subsidy (LIS) to Medicaid, Medicare, Medicare (astellaspharmasupportsolutions. • Help determine whether a Part D, Medigap, DoD, VA, com/docs/xtandi/XSS_Patient_ patient is eligible for assistance TRICARE, or any state patient or Enrollment_Form.pdf) and fax it from an independent co-pay pharmaceutical assistance program. to 1.855.982.6341. Retain a copy foundation and provide contact of your patient’s proof of income, information for foundations To enroll your patient in Xtandi which may include one of the that may be able to offer Patient Savings Program, complete following: support to your patient. the Xtandi Support Solutions • Copy of the patient’s most Patient Enrollment Form recent tax return REIMBURSEMENT (astellaspharmasupportsolutions. • Copy of the patient’s most ASSISTANCE com/docs/xtandi/XSS_Patient_ recent W-2 form Enrollment_Form.pdf), including • Copy of the patient’s 1099 Xtandi all patient and healthcare provider Social Security form Support Solutions signatures, and fax the completed • Copy of the patient’s most recent Specialists are available to help form to 1.855.982.6341 or contact Social Security benefits letter patients find the best option to your preferred network specialty • Copy of the patient’s latest gain rapid access to Xtandi. Xtandi pharmacy to determine eligibility pay stubs for 4 consecutive Support Solutions can help with: and enroll in the program. pay periods. • Reimbursement support (benefit verification, prior authorization Uninsured Patients Once your patient is approved for tracking, appeal assistance) The Astellas Access Program is assistance under the Astellas Access • Prescription triage to a specialty for patients without prescription Program, Xtandi Support Solutions pharmacy in the Xtandi Support coverage for Xtandi. The Program will notify both the prescriber and Solutions network provides free Xtandi to patients patient. An initial 30-day supply • Questions on using specialty who qualify. Eligibility is deter- of Xtandi is then shipped directly pharmacies mined on a patient-specific basis. to the patient’s home. Subsequent • Support for in-office dispensers To be eligible for the Astellas Access 30-day refills are sent automatically • Referrals to programs to help Program patients must meet the to the patient’s home each month with out-of-pocket expenses following criteria: they are enrolled in the program. • Facilitating immediate access • Patient is uninsured or has to Xtandi via the Quick Start+ insurance that has denied Medicare Patients program coverage for Xtandi Medicare typically covers Xtandi • Determining patient eligibility under the Medicare Part D pre- for the Astellas Access Program.

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Benefits Verification • If the healthcare provider re-verification process can also Xtandi Support Solutions performs returns the completed form help renew prior authorization and the benefits verification upon receipt to Xtandi Support Solutions, identify changes to a patient’s need of the patient enrollment form. After Xtandi Support Solutions will for financial assistance. performing a comprehensive assess- submit the completed form to ment of patient coverage for Xtandi, the patient’s insurer. Education and Xtandi Support Solutions provides Refill Reminders patients with a summary of benefits At the request of the healthcare Xtandi Support Solutions is that includes: provider, Xtandi Support Solutions available to help patients stay • The patient’s insurance coverage will follow up with the patient’s compliant with therapy though requirements for Xtandi insurer to confirm receipt of the education and reminder calls. • Requirements for prior prior authorization form, check The specialty pharmacies in our authorization, step edit, or on the status of the form, and preferred network will coordi- other coverage restrictions determine the outcome. Xtandi nate with you and your patients • Cost-sharing responsibility, Support Solutions will follow to answer questions, track refill including deductibles, up with the healthcare provider schedules, and continue to ship co-insurance or co-payment, regarding the prior authorization Xtandi to patients quickly. Go to and out-of-pocket maximums results, inform them if any addi- astellaspharmasupportsolutions. • A list of specialty pharmacies tional information is required, com/products/xtandi/specialty_ that participate in your patient’s and assist with denial appeals pharmacies/index.aspx for more insurance coverage. as necessary. information on our preferred specialty pharmacy network. Xtandi Support Solutions will send Prior Authorization your office a summary of benefits Denial Appeals Astellas Access typically within 2 hours of receipt If a patient’s insurer denies a claim eService Portal of the patient enrollment form. or prior authorization request, The Astellas Access eService tool is Xtandi Support Solutions can assist an interactive website for healthcare Prior Authorization with the appeals process by: providers to securely and efficiently Xtandi Support Solutions will • Identifying the reason for the submit, track, and manage requests determine whether a patient’s denied claim or prior authoriza- online. Available 24 hours a day, plan requires prior authorization tion request eService allows providers to: for Xtandi, and if it does, how to • Determining the additional • Submit, track, and view the obtain the prior authorization. required documentation results of benefit verifications Xtandi Support Solutions will also: • Informing the healthcare • Submit, track, and view the • Determine whether prior autho- provider what information is results of Astellas Access rization is required needed and where to send the Program℠applications. • Provide a summary of prior appeal authorization requirements and • Tracking and relaying the status Go to https://eservice.astellasaccess. obtain the appropriate prior of the appeal. com/ to get started with Astellas authorization form Access eService. • Pre-populate the prior authori- Re-Verification zation form using the informa- Xtandi Support Solutions is tion provided on the patient available to help you re-verify a enrollment form patient’s benefits, allowing you to • Send the form to the healthcare know the most up-to-date benefit provider to complete and sign information when refilling a patient’s Xtandi prescription. The

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 33 TABLE OF CONTENTS AstraZeneca

AstraZeneca

Oncology-related Products: Arimidex® (anastrozole), Caprelsa® (vandetanib), Casodex (bicalutamide), Faslodex® (fulvestrant), Iressa (gefitinib), Lynparza® (olaparib), Tagrisso™ (osimertinib) tablets, Zoladex® (goserelin acetate)

Patient and Reimbursement Assistance Websites www.azandmeapp.com www.MyAccess360.com

PATIENT ASSISTANCE tion assistance program can help completed form to 1.800.961.8323. patients who do not have prescrip- NOTE: Faxed applications must AZ&Me™ Prescription tion drug coverage and who meet be sent from the doctor’s office Savings Program the eligibility criteria listed below. in order for their prescription If patients take certain AstraZeneca Highlights of the program include: to be processed. Or enroll by medicines and cannot afford them, • AstraZeneca medicines phone by calling 1.800.AZandMe they may qualify for one of the provided at no cost. (292.6363). AZ&Me Prescription Savings Pro- • There is no cost to sign up for grams. To determine which AZ&Me the program. Eligibility requirements. Patient is Prescription Savings Program patients • Once accepted, patients remain a U.S. citizen or has a Work Visa may be eligible for call: 1.800. enrolled for up to one year. At or Green Card. Patients are not AZandMe (1.800.292.6363) or go the end of that year, patients currently receiving prescription drug online to: www.azandmeapp.com. can reapply. coverage under a private insurance Have the following information • Drugs are mailed to the or government program, or receiving available before beginning the pre- provider or the patient’s home. any other assistance to help pay for screening process: • The provider, patient, or medicine. Patients have an annual • The name(s) of the AstraZeneca caregiver can request refills. income that is at or below: medication(s) the patient is • Providers and patients can • $35,000 for a single person prescribed review the list of medicines • $48,000 for a family of two • Information about whether the available through this program • $60,000 for a family of three patient has prescription drug at: azanmeapp.com/resources/ • $70,000 for a family of four coverage prescription_product_list. • $80,000 for a family of five. • Information about the patient’s total household income. To enroll your patient in the NOTE: Income eligibility criteria AZ&Me Prescription Savings for some specialty and/or oncology Patients Without Program by mail, download and Products may be different from Insurance complete the application form the income levels listed above. Call The AZ&Me Prescription Savings (azandmeapp.com/assets/app.pdf) 1.800.AZandMe (1.800.292.6363) Program can provide AstraZeneca and mail to: AZ&Me Prescription for more information or visit: medicines at no cost to qualified Savings Program, PO Box 898, azandmeapp.com/resources/ patients. This patient prescrip- Somerville, NJ 08876. Or fax the specialty_oncology_income_

34 / ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 35 TABLE OF CONTENTS AstraZeneca

eligibility. Apply by following the • Loss of employment The AZ&Me Prescription Savings instructions discussed above. • Change in income program for healthcare facilities is • Loss of, or change in, prescrip- open for facility enrollment. If you Patients with Medicare tion drug coverage would like more information on Part D Insurance • Marriage the program, call 1.866.325.8198 The AZ&Me Prescription Savings • Change in household number. to request a brochure that provides program provides AstraZeneca additional details regarding facility medicines at no cost to qualified Healthcare Facilities eligibility and requirements for patients enrolled in a Medicare The AZ&Me Prescription Savings enrollment. If upon review of the Part D prescription drug coverage Program helps provide AstraZeneca brochure, you feel that your facility plan but who are having difficulty medicines to low-income patients can meet the requirements of the affording their AstraZeneca through qualifying facilities such as: program and you are interested in medicine(s). Highlights of the • Disproportionate share hospitals applying, call our program special- program include: • Community health centers ists for an enrollment kit. • AstraZeneca medicines • Community free clinics NOTE: enrollment in AZ&Me provided at no cost. • Central fill pharmacies Prescription Savings Program • There is no cost to sign up for • Charitable pharmacies. for healthcare facilities is limited this program. based on facility eligibility, which • Once enrolled, patients remain Highlights of the program include: is subject to change, and program enrolled for the remainder of the • Bulk replacement program availability. calendar year; patients may re- based on a facility’s qualifying apply the following calendar year. product utilization. REIMBURSEMENT • Drugs are mailed to the • Facilities can receive and dispense ASSISTANCE provider or the patient’s home. AstraZeneca medicines at no cost • The provider, patient, or or for a nominal, facility-assessed Access 360™ caregiver can request refills. dispensing fee from their outpa- This comprehensive affordabil- tient pharmacy or dispensary to ity and reimbursement program To be eligible for assistance, qualified patients. provides a range of support Medicare Part D beneficiaries • Facilities remain enrolled for two options, including: must not be eligible for or enrolled years and then may re-enroll. • Dedicated Access 360 Specialists in Limited Income Subsidy (LIS) • Prescriptions are provided to who can develop an in-depth for Medicare Part D, and meet patients at the point of care. benefits investigation report the annual income limits above. • Identification of distribution Apply by following the instructions Facility qualification criteria options and pharmacy coor- discussed above. includes, but is not limited to: dination for submissions and • Existence of an on-site, licensed shipments Patients Experiencing outpatient pharmacy or dispensary • Prior authorization research can Financial Hardship • Tax-exempt status follow up with the insurance com- If patients have experienced a life • Robust policies and procedures pany until a decision is obtained changing event in the past year, and • Facility patient eligibility • Appeals support in the event of their financial documentation does criteria that is consistent with a denial not accurately reflect their current AstraZeneca Program guidelines • Assistance determining which situation, they should apply for for patient eligibility, including affordability programs are the AZ&Me Prescription Savings patient income thresholds, appropriate for patients and Program, as they may still meet the lack of patient prescription directions on how to apply. criteria to enroll. Some examples of insurance, and annual patient this type of event would be: eligibility review.

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 35 TABLE OF CONTENTS Bayer HealthCare

Bayer HealthCare Pharmaceuticals, Inc.

Oncology-related product: Nexavar® (sorafenib) tablets, Stivarga® (regorafenib) tablets, Xofigo® (radium Ra 223 dichloride injection)

Patient and Reimbursement Assistance Websites hcp.xofigo-us.com/patient-financial-assistance reachpatientsupport.com

PATIENT ASSISTANCE authorization to 1.855.963.4463. co-pay/co-insurance assistance. Registered users can also submit an Once approved, your patient Xofigo Access Services application for patient assistance via receives an approval letter with a Uninsured Patients the secure Xofigo Access Services commercial co-pay/co-insurance You must apply for assistance on Provider Portal: assistance identification (ID) card. your patient’s behalf by submit- xofigoaccessonline.com. Patients approved for assistance ting a completed application (hcp. will not have to pay anything xofigo-us.com/downloads/PP- Co-Pay Assistance for to access Xofigo. Call an Access 600-US-1278_Xofigo_Access%20 Patients with Private Counselor at 855.6XOFIGO Services%20PAP_Copay%20App_ Commercial Insurance (1.855.696-3446), 9:00 am to 8:00 Digital.pdf), including a signed You must apply for assistance on pm EST, Monday through Friday, if patient authorization. Eligibility your patient’s behalf. Eligibility you have any questions or to obtain criteria include: criteria include: more information. Registered users • Financial criteria based on • Financial criteria based on can also submit an application for adjusted gross household adjusted gross household patient assistance via the secure income (documentation of income (documentation of Xofigo Access Services Provider income is required) income is required) Portal: xofigoaccessonline.com. • Residency in the United States, • Residency in the United States, including the District of including the District of Co-Pay Assistance for Patients Columbia, Puerto Rico, Guam, Columbia, Puerto Rico, Guam, Insured by Public Payers or the U.S. Virgin Islands or the U.S. Virgin Islands Medicare beneficiaries and patients • Treatment provided in an • Treatment provided in an with other government insurance outpatient setting. outpatient setting. who need help paying for treatment with Xofigoare not eligible for Call an Access Counselor at You and your patient must sign and co-pay assistance through the 855.6XOFIGO (1.855.696-3446), submit the Application for Patient Xofigo Access Services. These 9:00 am to 8:00 pm EST, Monday Assistance/Commercial Co-pay patients may be eligible for co-pay through Friday, if you have any Assistance Form (hcp.xofigo-us. or co-insurance assistance through questions or to obtain more infor- com/resources) that includes a an independent co-pay assistance mation. Fax a completed applica- signed patient authorization and foundation. If co-pay assistance tion, including the signed patient an assignment of commercial needs are identified, a Xofigo Access

36 / ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 37 TABLE OF CONTENTS Bayer HealthCare

Services Access Counselor can Uninsured or Underinsured • Claims tracking provide information about other Patients • Billing and coding information foundations that will determine a On approval, eligible patients will • Payer policy information. patient’s eligibility for co-pay or co- be provided a monthly supply of insurance assistance based on their their prescribed therapy for 12 To access these services, call own criteria. months. Eligibility requirements 1.855.6XOFIGO (1.855.696.3446) include, but are not limited to: 9:00 am to 8:00 pm EST, Monday REACH® • Meeting the financial criteria through Friday. You can also access Call REACH (Resources for Expert with proof of income these services online 24/7 through Assistance and Care Helpline) • Completing the enrollment the Xofigo Access Services Provider Service Counselors for: form, including patient and Portal: xofigoaccessonline.com. • Co-pay assistance for physician signatures Or download these reimburse- privately-insured patients • Patients must reapply every ment tools: • Alternate coverage research for 12 months (or any time there • Quick Reference Reim- uninsured and underinsured is a change in status of bursement Guide Hospital patients insurance coverage). Outpatient: hcp.xofigo-us. • Referral of qualified patients com/downloads/PP-600-US- to charitable organizations Referrals for Patients with 1292_Xofigo_Quick%20 for assistance with their Federally-Funded Insurance Reference%20Reimb% out-of-pocket expenses. Independent charitable organiza- 20Guide_Hospital%20 For more information, go to tions may assist patients who Outpatient_Digital_1.pdf reachpatientsupport.com or call cannot afford their prescription • Quick Reference Reimburse- 1.866.639.2827. medication and/or their out-of- ment Guide Freestanding pocket costs. REACH Service Center: hcp.xofigo-us.com/ Co-Pay Program Counselors can provide eligible downloads/PP-600-US- There are two ways to register for patients information and transfer 1286_Xofigo_Quick%20 this program: 1) through select the right patient to the right orga- Reference%20Reimb%20 specialty pharmacy providers or nizations. For Medicare patients, Guide_Freestanding_ 2) through the REACH program. REACH will provide information Digital.pdf. Program highlights: regarding Part D plan options • Currently a $0 co-pay and up and applications for low-income REACH® to $4,000 per month and up to subsidy. For Medicaid patients, Call REACH Service $16,000 per year per patient for REACH will provide information Counselors for: privately-insured patients about the application process and • Benefit verification, prior • If prior authorizations are follow-up support if the patient authorizations, denials, and delayed or denied, patients decides to apply for assistance. appeal information will be assessed for temporary • Specialty pharmacy providers patient assistance REIMBURSEMENT identification • Only privately-insured patients ASSISTANCE • Information on Medicare who were not previously Part D plan enrolled in the REACH Co-Pay Xofigo Access Services • Medicaid application Assistance Program are eligible; Comprehensive reimbursement and enrollment. patients enrolled in Medicare, assistance, including: Medicaid, or any other govern- • Insurance benefit verifications ment-funded programs are not • Prior authorization support eligible for the co-pay program. • Claims appeal research and information

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 37 TABLE OF CONTENTS Boehringer Ingelheim

Boehringer Ingelheim Pharmaceuticals, Inc.

Oncology-related product: Gilotrif™ (afatinib)

Patient and Reimbursement Assistance Website gilotrif.com/solutions_plus.html

PATIENT ASSISTANCE BI Cares Foundation. (NOTE: edgeable reimbursement specialists patients must be U.S. residents.) assist with the coverage and reim- Solutions Plus™ bursement process throughout the This program offers a range of To determine if a patient is eligible patient’s Gilotrif treatment journey. services to help alleviate financial for programs offered by or through To get patients started on therapy concerns around access. Insurance Solutions Plus, BI Cares Founda- as easily and quickly as possible coverage should not be a barrier to tion, or other support programs, and minimize reimbursement chal- cancer treatment—we will explore use the online financial tool at: lenges, Solutions Plus provides multiple options to help a variety gilotrif.com/solutions_plus/access_ assistance with: of patients afford their treatment, and_reimbursement_solutions/ • Benefit verification. Upon including: financial_support_tool.html. Or enrollment, reimbursement • Commercially insured patients enroll your patient by calling specialists investigate and verify who are eligible pay no more 1.877.814.3915, 8:00 am to coverage for patients within 2 than a $25 co-pay per month 8:00 pm EST or by downloading business days from initiation. through the Co-pay Assistance the application at: gilotrif.com/ • Prior authorization. Reimburse- Program. (NOTE: patients must content/dam/internet/pm/gilotrif4/ ment specialists anticipate and be U.S. residents.) com_EN/documents/PC-GF-0117- communicate prior authoriza- • Publicly insured patients are PROF%20.pdf. Complete the entire tion requirements for payers. If connected to alternative funding enrollment form with a signed prior authorization is needed support, which may help offset patient authorization form and and the patient receives Gilotrif co-pays, deductibles, or other Gilotrif prescription and fax it to: tablets from our dedicated treatment-related expenses. 1.866.240.4556. Fax confirmation specialty pharmacy partner, If denied alternative funding, will be provided within 2 hours of Accredo, then Solutions Plus publicly insured patients may be enrollment form submission. may assist with submission and eligible for BI Cares Foundation tracking of prior authoriza- support. (NOTE: patients must REIMBURSEMENT tion consistent with health plan be U.S. residents.) ASSISTANCE requirements. • Uninsured and underinsured • Gilotrif Bridge. If a patient ex- patients who have been denied Solutions Plus periences a payer delay >7 days financial assistance from other This program helps providers and for the FDA-approved indica- foundations may be eligible for patients navigate coverage and tion, they may receive a 15-day free medication through the reimbursement challenges. Knowl- supply of Gilotrif tablets. This

38 / ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 39 TABLE OF CONTENTS Boehringer Ingelheim

program allows patients to start Boehringer Ingelheim Access content/dam/internet/pm/gilotrif4/ therapy and avoid a prolonged Reimbursement and Distri- com_EN/documents/PC-GF-0117- delay. NOTE: This program is bution Managers provide PROF%20.pdf. Complete the entire for commercially and publicly additional support with the enrollment form with a signed insured patients treated with appeals process. patient authorization form and Gilotrif for the FDA-approved Gilotrif prescription and fax it to: indication. Providers can obtain a Solutions 1.866.240.4556. Fax confirmation • Denials & appeals. Reim- Plus enrollment form by calling will be provided within 2 hours of bursement specialists follow 1.877.814.3915, 8:00 am to enrollment form submission. up with programs when 8:00 pm EST or download the patient claims are denied, and application at: gilotrif.com/

Insurance Verification Form

Update q New q Patient Name: ID/SSN #:

Patient Insurance ID Group Policy # Insurance Company: (if different) Primary Insurance? Secondary? Tertiary? Authorization/referral #

Name of Contact Date/Time of Auth:

Phone/Fax/Address for Auth:

Effective Date: PCP: Tel #

Specific Pharmacy Requirement: q Mail order:

Co-insurance/Co-pay: Cap for drugs or diagnosis: $

Catastrophic Coverage or Stop-loss When?

Medicare Card Number: Effective:

q Part A q Part B Medicare HMO? Medicare Supplement? q Yes q No Medigap Plan?

Does policy include a Deductible? q Yes q No Co-insurance? q Yes q No Prescription Drugs? q Yes q No

Medicaid? q Yes q No Pending? Spend Down? q Yes q No

Share of Costs? Spend Down Amount $

Source. The ACCC Financial Advocacy Network. accc-cancer.org/FAN.

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 39 TABLE OF CONTENTS Bristol-Myers Squibb

Bristol-Myers Squibb

Oncology-related products: Empliciti™ (celotuzumab), Erbitux® (cetuximab), Ixempra® (ixabepilone), Opdivo® (nivolumab), Sprycel® (dasatinib), Yervoy® (ipilimumab)

Patient and Reimbursement Assistance Website bmsaccesssupport.bmscustomerconnect.com/oncology/services /patient-financial-assistance

PATIENT ASSISTANCE Other restrictions may apply. Final BMS Access Support determines determination of program eligibility patient eligibility, including BMS Access Support™ is based upon review of completed verifying commercial insurance Bristol-Myers Squibb (BMS) Access application. coverage to establish the appropri- Support can help identify financial ate benefit amount. BMS Access assistance programs for eligible Enrollment is simple. The provider Support then notifies the provider patients who need help managing collects the patient’s name, address, and patient of enrollment and the the cost of treatment. The appro- insurance carrier, and member appropriate next steps. Finally, priate program will depend on the identification number. The provider the provider submits the primary patient’s coverage. then completes the application claim to the commercial insurance through BMS Access Support in one carrier. If the Explanation of BMS Oncology of the following ways: Benefits form indicates that your Co-Pay Program • Use the BMS Access Support patient has a cost-sharing expense, This program (www.bmscustomer Form Wizard. notify BMS Access Support and connect.com/bmsaccesssupport/ • Download the enrollment submit the required documentation oncology/services/patient-financial form on your computer and to initiate appropriate next steps. -assistance/copay) is designed to fax to 1.888.776.2370. For questions or to confirm receipt assist with out-of-pocket co-pay, (NOTE: Providers will need of the application, call the Support deductible, or co-insurance costs to create a login and password Center at 1.800.861.0048, 8:00 am for eligible, commercially insured to access the form.) Check the to 8:00 pm EST, Monday through patients who have been prescribed box for the BMS Oncology Friday. You can also enroll online certain BMS products. Patients Co-Pay Program. through the BMS Access Support with state or federally-funded • Enroll online with our secure secure portal: www.MyBMS insurance plans are not eligible portal: MyBMSOncology OncologyCases.com. for this co-pay program. Enrolled Cases.com. patients pay the first $25 of their co-pay per infusion. BMS will cover the remaining amount up to $25,000 per year per product.

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Assistance for Assistance for Patients to create a login and password Uninsured Patients with Federally-Funded to access the form) and fax For patients without prescription Insurance Plans to 1.888.776.2370. drug insurance, or for patients that Patients with federally-funded • For questions or to confirm are underinsured, BMS Access insurance plans are not eligible receipt of the application, Support can refer them to indepen- for co-pay assistance programs call the Support Center at dent charitable foundations that sponsored by Bristol-Myers Squibb. 1.800.861.0048, 8:00 am may be able to provide financial However, there are independent to 8:00 pm EST, Monday support, including, the Bristol-My- foundations that can help. BMS through Friday. ers Squibb Patient Assistance Foun- Access Support can refer providers • You can also enroll, track, and dation: bmspaf.org. This charitable to the foundation offering the best manage your cases online with organization provides medicine, support for their specific patient the BMS Access Support secure free of charge, to eligible, uninsured and help them through the applica- portal: www.mybms patients who have an established tion process. It is important to note oncologycases.com. financial hardship. The Bristol- that these foundations are indepen- Myers Squibb Patient Assistance dent and not affiliated with Bristol- BMS Access Support Care Coordi- Foundation accepts the BMS Access Myers Squibb. Each foundation has nators are always local. That means Support application. Patients may its own eligibility criteria and evalu- a familiarity with your office, know- be eligible for assistance through ation process. Bristol-Myers Squibb ledge of your patients’ cases, and the Bristol-Myers Squibb Patient cannot guarantee that a patient experience with the insurers in your Assistance Foundation if they: will receive assistance. For details, area. Program Care Coordinators 3 Do not have insurance contact BMS Access Support at are available to your oncology coverage, or have been denied 1.800.861.0048. office Monday through Friday, coverage for a requested from 8:00 am to 8:00 pm EST at medicine REIMBURSEMENT 1.800.861.0048. 3 Are enrolled in a Medicare ASSISTANCE Part D plan and have spent at BMS Access Support: least 3 percent of their yearly BMS Access Support: Prior Authorization income on out-of-pocket costs Benefits Investigation Assistance for prescription medicines in the From the moment a treatment BMS Access Support can provide current year plan is determined, BMS Access plan-specific prior authorization 3 Are being treated on an outpa- Support is here to help you stream- forms when one is required by the tient basis line your patients’ experience. patient’s health plan. Some health 3 Live in the United States, Puerto We can review patients’ insurance insurers require that a prior autho- Rico, or the U.S. Virgin Islands coverage for Bristol-Myers Squibb rization be issued before certain 3 Meet the income limits for the products and help identify ad- items or services are covered. This requested medicine. ditional sources of support. Work may require specific forms and with BMS Access Support as early supporting documents before a These are just some of the eligibil- as possible. To begin the benefits prior authorization may be issued ity requirements. Other eligibil- investigation process: (e.g., medical history, physicals, ity criteria may apply. For more • Use the BMS Access Support pathology reports, etc.). When information about eligibility and Form Wizard. Or download the necessary, make sure your patients to obtain an enrollment applica- enrollment form at: understand coverage for the service tion, call the Bristol-Myers Squibb bmsaccesssupport.bmscustomer before they have a financial obliga- Patient Assistance Foundation, at connect.com/oncology/services/ tion to their provider. Please note: 1.800.736.0003. benefits-investigation. If a prior authorization requirement (NOTE: Providers will need is not met, some health insurers

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 41 TABLE OF CONTENTS Bristol-Myers Squibb

may deny coverage, even if the • Coverage decisions may be More questions? Download the full claim would have otherwise been made by an insurer before Reimbursement Guide at: covered. If coverage is denied, the treatment is rendered or www.bmscustomerconnect.com/ either the physician or the patient after a claim is filed. Coverage bmsaccesssupport/servlet/servlet.Fi may appeal. See below for details decisions that are made before leDownload?file=00Pi000000AQA on prior authorization appeals. a treatment regimen is initiated iDEAX. are often referred to as “prior Some insurers will make a predeter- authorization” or “coverage mination of coverage decision upon determinations.” request. This generally applies to an • Medicare Part B and many item or service that does not require other health insurers will not a prior authorization. If a predeter- make a coverage decision mination decision denies coverage, regarding individual patients either the physician or patient may before a claim is filed. Coverage appeal the decision with the insurer, is considered only at the time a in the same manner an appeal claim is presented for payment. can be made on a denial of prior • The billing provider can usually authorization. appeal an insurer’s decision to deny coverage for a claim. For prior authorization assis- Appeals are almost always tance from BMS Access Support, subject to timeliness require- providers will need: ments. The window of time • Patient demographics allowed for a provider to • Complete insurance information appeal an unfavorable coverage and copy of card decision usually begins on the • Physician demographics and date a claim was adjudicated signature (processed) by the insurer. • Diagnosis and drug name. • If the health insurer approves an appeal, you will be notified and BMS Access Support: the claim will be reconsidered. Claims Appeal • If the health insurer denies the Assistance appeal, contact BMS Access Almost all health insurers have Support for further assistance at a specific process to appeal an 1.800.861.0048. unfavorable coverage decision. • Each plan has its own process BMS Access Support can assist in and timeline for appeals. The navigating the appeals process. appeals process for Medicare However, the preparation and sub- Part B contractors is determined mission of documents to support by the Centers for Medicare and the appeal is the responsibility Medicaid Services (CMS). of the patient and/or healthcare provider. Bristol-Myers Squibb and its agents make no guarantee regarding the outcome of appeals assistance. When you’re filing an appeal, keep in mind:

42 / ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 43 TABLE OF CONTENTS Celgene Oncology

Celgene Oncology

Oncology-related products: Abraxane® for Injectable Suspension (paclitaxel protein-bound particles for injectable suspension) (albumin-bound), Istodax® (romidepsin) for Injection, Pomalyst® (pomalidomide), Revlimid® (lenalidomide), Thalomid® (thalidomide), Vidaza® (azacitidine)

Patient and Reimbursement Assistance Website celgenepatientsupport.com

PATIENT ASSISTANCE and fax the completed form to • Household income of $100,000 1.800.822.2496, or e-mail the or less (subject to random audit) Celgene Free completed form to: • Residence in the United States Medication Program [email protected]. or Puerto Rico The Celgene Free Medication 3. Enroll over the phone at Program is available to qualified 1.800.931.8691, ext. 4081, To learn more call 1.800.931.8691, patients who are uninsured or Monday through Friday, 8:00 Monday through Friday, 8:00 am underinsured: am to 7:00 pm EST. to 7:00 pm EST. • Your patients must meet required insurance and Celgene Commercial Third-Party financial criteria Co-Pay Program Financial Assistance • Celgene Patient Support can also This program is for eligible, For patients with Medicare, help you find outside programs commercially insured patients. If Medicaid, or other government- through which your patient may qualified, your patient’s out-of- sponsored insurance, Celgene qualify for financial support. pocket co-pay responsibility will Patient Support can help explore be $25 or less, depending on the deductible, co-pay, co-insurance, There are three ways to enroll your Celgene product they have been or premium assistance options patient in Celgene Patient Support. prescribed. This program provides with third-party organizations. up to $10,000 per calendar year to Celgene Patient Support will 1. Enroll online at: help meet deductible, co-pay, and walk your patient step-by-step celgenepatientsupport.com/ co-insurance costs. (Please note the through the process of securing enrollment. program does not cover adminis- financial support from these 2. Download the Celgene Patient tration fees.) Patients must meet third-party organizations. Celgene Support Enrollment Form in specified financial criteria to qualify Patient Support will also help English (celgenepatientsupport for assistance. To qualify patients locate transportation assistance .com/wp-content/uploads/CPS_ must have: options to assist with the costs of Application_Form_English.pdf) • Commercial and/or private traveling to and from the physi- or Spanish (celgenepatient insurance (Patients with cian’s office. If you have questions support.com/wp-content/ Medicare, Medicaid, or other call 1.800.931.8691, Monday uploads/CPS_Application_ government-sponsored coverage through Friday, 8:00 am to 7:00 Form_Spanish.pdf) are not eligible for this program) pm EST. You can also view a list

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 43 TABLE OF CONTENTS Celgene Oncology

of third party organizations that Prior Authorization may be able to lend financial Some health insurance plans support to your patient online require prior authorization for the at: celgenepatientsupport.com/ use of Celgene products. At your find-financial-help/. request, Celgene Patient Support will assist your office staff with Successful Start App the prior authorization process, Patients can access Celgene Patient and follow up with the insurance Support services on their mobile provider to determine the outcome. device or tablet using the Celgene You can download the Celgene Patient Support Successful Start REIMBURSEMENT Patient Support Prior Authorization App. The Successful Start App ASSISTANCE Checklist at: https://www.celgene allows patients to: patientsupport.com/wp- • Begin the Celgene Patient Celgene Patient content/uploads/Prior-Authoriza- Support enrollment process, Support Specialists tion-Checklist.pdf. Contact and request a Patient Support Patients are assigned a Celgene Celgene Patient Support at Specialist to call or email them Patient Support Specialist based on 1.800.931.8691 for assistance to address specific questions. the zip code of their doctor’s office. with prior authorizations. • Find and send information about the support available for The Celgene Patient Support Specia- Appeals the specific Celgene medica- list will work with your patient If your patient’s insurance company tion they have been prescribed, to resolve access issues to Celgene denies coverage for the Celgene including financial and insur- medications. With continual medication you have prescribed, ance-related support services. communication and consistent Celgene Patient Support can help • Find and connect with their follow-through, these special- facilitate the appeal. During the Celgene Patient Support Special- ists will streamline access to our appeals process your patient may ist by entering the zip code of products by helping you and your qualify for the Celgene Free Medi- their doctor’s office. patients with: cation Program. (See information • Benefits investigation about the program and eligibility To download the Successful Start • Prior authorization requirements above.) In order for App patients can either scan the • Appeals support Celgene Patient Support to assist QR code directly to their mobile • Understanding Medicare with the appeal, please provide the device, or search for “Celgene coverage following information within two Start” in the iTunes App Store or • Co-pay assistance (for qualified weeks of the insurance denial: Google Play. The Successful Start patients with commercial and/or • Copies of the front and back of App is available for iPhone, iPad, private insurance) the patient’s health insurance and Android devices. NOTE: These • Celgene Free Medica- card(s), including the patient’s resources are not available for all tion Program (for qualified drug card or copy of patient’s Celgene products. Patients and patients who are uninsured or information sheet clearly iden- caregivers seeking information on a underinsured). tifying insurance information, product not included the Successful including phone numbers and Start App should contact Celgene Contact Celgene Patient Support at claim submission address. Patient Support for Assistance. Call 1.800.931.8691, Monday through • Denial letter from payer 1.800.931.8691, Monday through Friday, 8:00 am to 7:00 pm EST. Or complete with appeal address. Friday, 8:00 am to 7:00 pm EST. send an e-mail to patientSupport@ • History and physical or consult celgene.com. Learn more at: letter and progress notes, and celgenepatientsupport.com. if applicable, related labora-

44 / ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 45 TABLE OF CONTENTS Celgene Oncology

tory reports. Last three months The current status of the patient, needed. including: • Letter of medical necessity (see • Date of recurrence, if applicable. below for guidelines). Please • Recommended treatment plan include drugs tried and failed with specific drugs, dosages, for this diagnosis. and schedules. • Appointment of representa- • Rationale for treatment, tive release form signed by the including unabridged reprints patient, parent, or guardian. or copies of applicable scientific This form allows us to act on and medical articles, compre- behalf of the patient during the hensive bibliographies, official appeals process. FDA drug labeling, etc. • Previous drug therapy, including In addition to helping you and status of specific lifetime your patient filing the appeal, maximum drug benefits and/or Celgene Patient Support will follow medical complications resulting up on the status of the appeal from other drug treatment until a decision is reached. For regimens. more information about Celgene Patient Support appeals assistance Download Celgene Patient call: 1.800.931.8691, ext. 4081, Support’s guidelines for writing a Monday through Friday, 8:00 am Letter of Medical Necessity here: to 7:00 pm EST. celgenepatientsupport.com/wp- content/uploads/Letter-of-Medical- Letter of Medical Necessity.pdf. Necessity In seeking an appeal from your patient’s insurance company, your Letter of Medical Necessity will be critical to the appeal outcome. Your letter should include a brief history of the patient, with the following information: • Patient name • Initial date of diagnosis • Significant laboratory tests and results • Specific cell type per pathology report, including documentation of metastasis, if applicable • Original treatment rendered, including all drugs, dosages, and schedules • Reason for stopping treatment and the patient’s clinical response.

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 45 TABLE OF CONTENTS Eisai

Eisai Co., Ltd

Oncology-related products: Akynzeo® (netupitant/palonosetron), Aloxi® (palonosetron hydrochloride), Halaven™ (eribulin mesylate), Hexalen® (altretamine) Capsules, Lenvima (lenvatinib) Capsules

Patient and Reimbursement Assistance Websites eisaipatientassistance.com eisaireimbursement.com

PATIENT ASSISTANCE process here: www.eisai Downloads/Akynzeo%20 patientassistance.com/eisaionline/ PAP%20Enrollment%20Form. The Eisai Patient eisaionline/login.action. pdf and fax the completed form to: Assistance Program 1.844.494.8063. Questions? Call This program provides Eisai Other online tools include: 1.855.EISAI.4.U (1.855.347.2448), medicines at no cost to financially • The Eisai Patient Assis- Monday through Friday, 8:00 am needy patients who meet program tance Program enrollment to 8:00 pm EST. eligibility criteria. To pre-screen form: eisaireimbursement. your patients for eligibility go to: com/Aloxi/downloads/ Akynzeo Savings eisaipatientassistance.com. This Eisai_Oncology_PAP_App_ Card Program pre-screening tool is intended to ALv_010411_pg2_writable.pdf. The Eisai Assistance and Support assist healthcare professionals in: The same form is used for all for You (E.A.S.Y.) Savings Program • Determining if a patient may be Eisai drugs. offers eligible, commercially insured eligible for the patient assistance • The Eisai Assistance Program Akynzeo patients a $0 co-pay on program insurance verification form each prescription with an $1,800 • Pre-populating enrollment eisaireimbursement.com/Aloxi/ annual limit. For cash patients, forms to be submitted for the downloads/Eisai_Oncology_IV_ Eisai Inc. will pay up to $150 patient assistance program. Form_113010.pdf. The same per prescription for a maximum form is used for all Eisai drugs. of $1,800 per year. No activa- The pre-screening process is an tion or enrollment is required. initial step to determine if a patient Akynzeo Patient Patients either receive their card may be eligible. A final enrollment Assistance Program through their healthcare provider, determination will be made once The Akynzeo Patient Assistance or download a card and print it at a complete and signed enrollment Program provides the drug at no home by visiting: www.akynzeo form and prescription are submitted or low cost to financially needy savingsprogram.com. via fax to: 1.866.57-EISAI patients who meet program (1.866.573.4724). Providers must eligibility criteria. Download Questions? Call 1.855.EISAI.4.U create a log-in to access this the enrollment application at: (1.855.347.2448), Monday through eisaireimbursement.com/Akynzeo/ Friday, 8:00 am to 8:00 pm EST.

46 / ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 47 TABLE OF CONTENTS Eisai

Restrictions and Conditions enroll call the E.A.S.Y. Program at: REIMBURSEMENT Eligibility Criteria: Good toward 1.855.EISAI.4.U (1.855.347.2448), ASSISTANCE the purchase of Akynzeo prescrip- Monday through Friday, 8:00 am tions. No substitutions permitted. to 8:00 pm EST. The Eisai Assistance Save this card to reuse with each Program prescription. Not available to Restrictions and Conditions This program is your dedicated patients enrolled in state or federal Eligibility Criteria: Good toward resource to help you answer your healthcare programs, including the purchase of Lenvima prescrip- coverage questions. The Eisai Assi- Medicare, Medicaid, Medigap, VA, tions. No substitutions permitted. stance Program provides you with DoD, or TRICARE. May not be Not available to patients enrolled information about benefits investiga- combined with any other coupon, in state and federal healthcare tions, reimbursement issues, coverage discount, prescription savings card, programs, including Medicare, options, and all other questions. free trial, or other offer. Federal law Medicaid, Medigap, VA, DoD, or What to expect when you contact prohibits the selling, purchasing, TRICARE. Offer only available to the Eisai Assistance Program: trading, or counterfeiting of this patients with private, commercial • Product specific reimbursement card. Such activities may result in insurance. May not be combined information imprisonment of 10 years, fines up with any other coupon, discount, • Understanding of coverage, to $25,000, or both. Void outside prescription savings card, free coding and payment issues the U.S. and where prohibited by trial, or other offer. Federal law • Insurance verification law. Eisai Inc. reserves the right to prohibits the selling, purchasing, processing rescind, revoke, or amend this offer trading, or counterfeiting of this • Prior authorization information at any time without notice. Patients card. Such activities may result in • Provide general guidance for and pharmacies are responsible imprisonment of 10 years, fines up appealing a denied claim for disclosing to insurance carriers to $25,000, or both. Void outside • Payer policy information. the redemption and value of the the U.S. and where prohibited by card and complying with any other law. Eisai Inc. reserves the right to The Eisai Assistance Program offers conditions imposed by insurance rescind, revoke, or amend this offer providers a wide range of online tools carriers or third-party payers. The at any time without notice. Patients for each of its products, including: value of this card is not contingent and pharmacies are responsible • Product information on any prior or future purchases. for disclosing to insurance carriers • Billing forms The card is solely intended to the redemption and value of the • ICD-10-CM diagnosis codes provide savings on any purchase of card and complying with any other • CPT drug administration codes Akynzeo. Use of the card for any conditions imposed by insurance • HCPCS Level II code one purchase does not obligate the carriers or third-party payers. The • National drug codes patient to make future purchases of value of this card is not contingent • Revenue codes Akynzeo or any other product. This on any prior or future purchases. • Medicare reimbursement rates offer will expire Oct. 3, 2019. This card is solely intended to • A checklist for claims provide savings on any purchase submission Lenvima Savings Card of Lenvima. Use of this card • Sample appeal letters Program for any one purchase does not • Sample letters of medical The E.A.S.Y. Co-pay Card for obligate the patient to make necessity Lenvima offers eligible com- future purchases of Lenvima or • Coverage scenarios flowchart. mercially insured patients a $0 any other product. This offer co-pay on each prescription, with will expire March 31, 2020. Contact the Eisai Assistance Program a $20,000 annual limit. No activa- at 1.866.61.EISAI , Monday through tion or enrollment is required. To Friday, 8:00 am to 8:00 pm EST.

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 47 TABLE OF CONTENTS Genentech

Genentech, Inc.

Oncology-related products: Alecensa™ (alectinib), Avastin® (bevacizmuab), Cotellic™ (cobimetinib) tablets, Erivedge™ (vismodegib), Gazyva™ (obinutuzumab), Herceptin® (trastuzumab), Kadcyla® (ado-trastuzumab emtansine), Perjeta™ (pertuzumab), Rituxan® (rituximab), Tarceva® (erlotinib), Xeloda® (capecitabine), Zelboraf® (vemurafenib)

Patient and Reimbursement Assistance Website www.genentech-access.com

PATIENT ASSISTANCE For insured patients who have 3. The GATCF Insurance coverage for their Genentech Attestation form. Genentech medicine: 4. The Patient Financial Access Solutions • Patient annual household Attestation form. The Genentech Access adjusted gross income (AGI) 5. The confirmation of Infusion to Care Foundation must be $150,000 or less and injection form. GATCF was created to help the out-of-pocket costs for his qualified patients receive certain or her Genentech medicine Forms can also be e-submitted Genentech medicines free of accounts for at least 10 percent online through Genentech’s Forms charge. GATCF might be able to of his or her annual house- and Documents page. Forms are help patients receive treatment if hold AGI drug-specific, so you must follow they meet specific financial and • All patient assistance options, in- the prompts at: genentech-access. medical criteria. cluding Genentech brand-specific com to access the correct forms. co-pay cards and support from Questions? Call Access Solutions For patients that are uninsured, or co-pay assistance foundations, at: 888.249.4918, Monday through have been rendered uninsured by have been exhausted Friday, 6:00 am to 5:00 pm PST. payer denial: • The patient meets medical • The patient’s annual household criteria determined by the NOTE: Eligible patients with a adjusted gross income (AGI) GATCF Clinical Advisory Medicare Part D plan who do not must be $100,000 or less, or Board. qualify for support from a co-pay patient’s annual household AGI assistance foundation may receive must be between $100,000 and To apply to GATCF, the following certain Genentech medicines free $150,000 and the out-of-pocket forms must be completed and of charge provided they meet costs for his or her Genentech submitted: the eligibility criteria for insured medicine accounts for at least 1. The Statement of Medical patients outlined above. 10 percent of his or her annual Necessity (SMN) form. household AGI 2. The Patient Authorization and Genentech BioOncology™ • The patient meets medical Notice of Release of Informa- Co-pay Card criteria determined by the tion (PAN) form in English This Co-pay Card helps patients GATCF Clinical Advisory Board. or Spanish. with the out-of-pocket costs of

48 / ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 49 TABLE OF CONTENTS Genentech

their prescription. Qualified individually. Need help with To begin with Access Solutions, patients must: enrollment? Call 855.MYCOPAY you must complete and submit the • Be covered by commercial (855.692.6729) or visit Statement of Medical Necessity or private insurance copayassistancenow.com. (SMN) form and have your patient • Be receiving treatment complete and submit a Patient that is consistent with the Referrals to Co-pay Authorization and Notice of Release FDA-approved use of the Assistance Foundations of Information (PAN) form. The Genentech therapy If patients need help with their SMN can be submitted online via • Not participate in a government medication co-pays, Access My Patient Solutions: gene.secure. funded healthcare program, Solutions can connect them to force.com/ihcp/GNE_CM_MPS_ such as Medicare, Medicaid, co-pay assistance foundations Login or download at genentech- Medigap, VA, DoD, or supporting their disease state. access.com. Forms are drug-specific, TRICARE Genentech does not influence or so you must follow the prompts to • Be 18 years of age and older control the operations of these access the correct forms. Patients • Currently live and receive co-pay assistance foundations, but can submit the PAN online at: treatment in the United States Access Solutions can assist patients pan.iassist.com/forms/bioonc or or Puerto Rico by making an appropriate referral download it online at: genentech- • There is no income requirement to a foundation that may be able to access.com. Forms are drug-specific, for the Genentech BioOncology help. Genentech cannot guarantee so you must follow the prompts to Co-pay Card Program. co-pay assistance once a patient has access the correct forms. been referred by Access Solutions. NOTE: Patients receiving funding The foundations to which patients Prior Authorization Assistance from the Genentech Access to are referred will have their own Access Solutions can help providers Care Foundation are not eligible criteria for patient eligibility, identify whether a prior autho- for the Genentech BioOncology including financial eligibility. rization (PA) is needed and help Co-pay Card Program. Some health them secure it. Simply complete plans might not accept a co-pay REIMBURSEMENT and sign a SMN form requesting card. Patients should contact their ASSISTANCE our assistance with the PA, as well insurance providers to find out as a signed and dated PAN form if their plan allows the use of Genentech (see instructions above). Access co-pay cards. Access Solutions Solutions can help providers submit Benefits Investigation the required PA forms and docu- Under the Genentech BioOncology Access Solutions conducts a benefits mentation. If the PA is not granted, Co-pay Card Program, the patient investigation (BI) to help you better Access Solutions can work with is responsible for a $25 co-pay understand your patient’s health providers to determine next steps. per prescription or infusion. The plan coverage for some or all of annual benefit limit of the co-pay the costs associated with treatment. Appeals card is $25,000, and the physician The BI can also determine if a prior If providers have prescribed a or patient must request the benefit authorization or patient assistance Genentech product but an insurer within 45 days of receiving the might be needed. To have Access has denied coverage, they can product or new program par- Solutions conduct a BI, providers appeal that decision. Access ticipants. Patients do not need the must request the assistance on the Solutions might be able to help physical card to receive benefits; signed SMN form. There are three providers resolve the situation. they just need their ID code. If a possible outcomes of a BI: Here is what you can do: patient is taking more than one 1. Treatment is covered 1. Understand why the request Genentech cancer medicine, these 2. Prior authorization is required or claim has been denied. This benefits apply to each medicine 3. Treatment is denied. should be in the insurer’s letter

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 49 TABLE OF CONTENTS Genentech

of denial or the patient’s Expla- • Test and lab results tional locations at a later date) nation of Benefits (EOB) letter. • Hospital admission/ • Prescriber licensing information, 2. Contact Access Solutions for emergency department including: a Prescriber National guidance as you put together an notes. Provider Identifier and State appeal. Use these resources to 3 Other supporting documents, license number (required). help you gather the documents including journal articles, and information you need for a abstracts, textbook excerpts, Providers will be asked to agree to successful appeal. practice guidelines, and/or the My Patient Solutions Practice 3. Complete and submit the compendia indications. Agreement. They must agree to required forms and documents these terms to proceed with My to the insurer before the appeal My Patient Solutions™ Patient Solutions. For support, call deadline. Access Solutions can My Patient Solutions allows you the 866.4ACCESS (866.422.2377), provide information about flexibility to work with Genentech 6:00 am to 5:00 pm PST, Monday this process. Access Solutions online whenever through Friday. Learn more at: you need. Features of My Patient genentech-access.com/hcp/learn- Here is a checklist of the forms and Solutions: about-our-services/our-services/ documents you may need for an • Paperless enrollment: Enroll my-patient-solutions. appeals package if an insurer denies your patients entirely online treatment to your patient. using electronic signatures. • Full benefits investigation NOTE: Each insurer and each reports: Review benefits inves- patient might need different infor- tigation reports for all your mation. Please review each denial patients enrolled in Genentech and the insurer’s guidelines, as well Access Solutions. as this website, to determine what • Patient case management: to include in your patient’s appeals Search for open or closed cases package. initiated online or via fax for 3 Statement of Medical Necessity easier patient case management, 3 Patient Authorization and re-enrollment or recertification. Notice of Release of • Customized alerts: Customize Information which email alerts you receive 3 Copy of the patient’s health about a patient’s case status so plan or prescription card you know what actions need to (front and back) be taken. 3 Appeal letter 3 Denial information including To register your program or the patient’s denial letter or practice, you will need the Explanation of Benefits letter following information: 3 Supporting documentation: • Primary Genentech products • Patient history and physical prescribed by your program or findings practice • Healthcare provider’s • User information including chart notes email addresses (you may add • List of current medications, additional users at a later date) with dose and frequency • Program or practice location • List of treatments tried information (you may add addi- without success

50 / ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 51 TABLE OF CONTENTS Incyte Corporation

Incyte Corporation

Oncology-related products: Jakafi® (ruxolitinib) tablets

Patient and Reimbursement Assistance Website www.incytecares.com

PATIENT ASSISTANCE Education and Support services. or less than 600% of the Federal If patients are not interested in Poverty Level (FPL). In addition, IncyteCARES signing up for these services, they patients insured through Medicare, IncyteCARES (Connecting to may opt out. Once IncyteCARES Medicaid, TRICARE, and health- Access, Reimbursement, Education receives the form, it will confirm care exchange plans are not and Support) offers ongoing the patient’s prescription drug eligible. An IncyteCARES special- support and resources to patients coverage and then coordinate with ist can help determine if patients being treated with Jakafi a specialty pharmacy to fill the pre- qualify for patient assistance. Call (ruxolitinib), including: scription. The specialty pharmacy 1.855.4.Jakafi (1.855.452.5234) to • Prescription insurance verifica- will then contact the patient to learn more. Terms of the program tion and prior authorization make delivery arrangements. are subject to change. support Then IncyteCARES will determine • Free drug and co-pay assistance, whether patients qualify for ad- Co-pay Assistance for those who qualify ditional services, such as co-pay or If patients are eligible, the co-pay • Referral to independent free product assistance. assistance plan for Jakafi may be nonprofit organizations or able to reduce their co-payment foundations that may be able to Uninsured Patients to no more than $25 per month. provide financial assistance Patients who do not have prescrip- Patients may be eligible for co-pay • Access to oncology nurses. tion drug coverage for Jakafi assistance if they have commercial may be eligible to receive the drug or private insurance, they are a Enrollment is easy. Download the free of charge through the resident of the U.S. or Puerto Rico, enrollment form at: incytecares. IncyteCARES patient assistance and they have a valid prescription com/pdf/jakafi-enrollment-form.pdf. program. This program helps for Jakafi for an FDA-approved people who do not have a pre- treatment. Patients must disclose NOTE: providers and patients scription drug plan, as well as the use of the co-pay card to their must work together to fill out those whose plans have turned insurers. The amount of savings the enrollment form. Completed them down for Jakafi treatment. on Jakafi will not exceed $8,300 forms should then be faxed to: Certain conditions apply for per month and $25,000 per year. 1.855.525.7207. In most states, prescription savings. Patients may Limit one 30-day supply per 30 the enrollment form will serve as be eligible if they are a resident of days. Card is valid for one year the patient’s initial prescription the U.S. or Puerto Rico and their after activation, after which time for Jakafi. By signing the form, the household size and annual income a card must be re-activated to patient is automatically enrolled meet certain criteria, including continue use. Patients must be 18 in the Access, Reimbursement, earning less than $125,000 a year years or older to eligible for co-pay

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 51 TABLE OF CONTENTS Incyte Corporation

assistance. Uninsured, cash-paying • The amount of the co-pay, if the will ask for more information patients are not eligible. Not patient knows this information. from the provider before deciding valid for patients covered under • The patient’s household income. to pay for the patient’s Jakafi. state or federally-funded health- If possible, patient should have IncyteCARES will work with care programs, such as Medicare, supporting documentation such physicians to provide the necessary Medicaid, or TRICARE. Call as a pay stub, tax return, or dis- information to their patient’s 1.855.4.Jakafi (1.855.452.5234) ability form on hand. healthcare plan. In addition, if a to learn more. Terms of the healthcare plan will not pay for program are subject to change. Patients will then need to fill out Jakafi, IncyteCARES can help an application. Here are some providers and patients understand Temporary Access questions they might want to ask what needs to be provided to the Eligible patients experiencing the foundation to get started: healthcare plan to appeal the denial. coverage delays greater than 3 • How long does the approval While IncyteCARES cannot apply business days can receive a free process take after I apply for the appeal, it can help providers 30-day supply of Jakafi. To qualify, for help? and patients determine the steps they patients must be eligible for co-pay • How will I be told if I am may need to take to overturn the assistance and provide proof of approved for or denied help denial. If patients experience insur- insurance claim form submission. from you? ance coverage delays, IncyteCARES • Will my doctor also be told may be able to provide access to Referral to an Independent what you decide? Jakafi. Eligible patients who have Non-profit Organization • If I am approved, where are the been prescribed Jakafi for an If patients are not eligible for one of payments sent? FDA-approved indication, and our prescription savings programs, • How long can I expect to who are experiencing an insurance IncyteCARES may refer them to receive this help? coverage delay greater than three other resources, such as indepen- business days, can receive a free, dent non-profit organizations and Each application requires patients 30-day supply of Jakafi after proof co-payment assistance foundations to verify their financial needs. It can of claims submission is provided. that may be able to help with their take from two weeks to 30 days for The free product is offered to co-payment. Each of these organi- a foundation to review an applica- eligible patients without any zations has its own set of rules, and tion. If patients are turned down by purchase contingency or other Incyte does not influence or control one foundation, IncyteCARES may obligation. For more information, them in any way. To apply to a be able to refer them to another contact IncyteCARES. foundation, patients will need to organization. gather some information, including: • All of the patient’s medical REIMBURSEMENT conditions and treatments. ASSISTANCE • The provider’s name, address, telephone number, and IncyteCARES fax number. A trained IncyteCARES special- • The patient’s healthcare plan ist will work with providers and information. Patients should patients to provide assistance with have their insurance card prescription drug plan requirements ready when they contact that must be met before patients IncyteCARES. If they have can get access to Jakafi. Some more than one healthcare plan, healthcare plans may require prior have all the information ready. authorization, which means they

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Insys Therapeutics, Inc.

Oncology-related products: Subsys® (fentanyl sublingual spray)

Patient and Reimbursement Assistance Website subsysspray.com/what-is-subsys/copay-savings-program

PATIENT ASSISTANCE site. If patients have activated a Healthcare providers are respon- co-pay savings card and are not sible for providing any medical Co-Pay Savings taking advantage of the $500 off necessity justifications. Questions? Program each prescription, they should call Call 1.888.280.5732. The Subsys Savings Program—sim- 1.855.766.6502 to check their ilar to a coupon—can offer patients activation status and obtain their free product and up to $500 off member ID number. Only one card each additional prescription of per patient can be activated. Subsys (fentanyl sublingual spray). This program is for commercially REIMBURSEMENT insured and cash-paying patients ASSISTANCE only. Any patient for whom any part of any prescriptions for Subsys Prescriber Prior is or will be covered by Medicaid, Authorization Support Medicare (including Medicare Reimbursement assistance and free Advantage or Part D Prescription product is available for patients Plans), any state’s prescription during the prior authorization drug programs, or any other public process. To participate, providers payer program is not eligible for simply need to “opt-in” to the Insys this co-pay program. If any other Reimbursement Center program by part of a patient’s prescription is completing the prior authorization paid by a non-governmental third- assistance form at: subsysspray. party payer, the patient must attest com/prior-auth-co-pay-assist. to having disclosed this offer to the (NOTE: Free product not available third-party payer. for Medicare, Medicaid, and TRICARE patients. Prior Authori- Enrollment is easy. Patients zation Assistance is available for all simply complete a short form on insured patients.) the Subsys patient reimbursement and assistance website: Next a dedicated team of prior subsysspray.com/what-is-subsys/ authorization specialists will assist copay-savings-program. Patients providers throughout the prior can then download their Subsys authorization process—all the way Savings Card directly from the up to and including external review.

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 53 TABLE OF CONTENTS Ipsen

IPSEN Biopharmaceuticals

Oncology-related products: Somatuline® Depot (lanreotide) Injection

Patient and Reimbursement Assistance Website ipsencares.com

PATIENT ASSISTANCE non-profit organization) and/or continued benefit. Patients with free product for eligible patients co-pays, co-insurance, or out-of- Ipsen CARES under the Ipsen CARES Patient pocket costs greater than $805 will The Ipsen CARES (Coverage, Assistance Program pay no more than $5. There are five Access, Reimbursement & • Coordination of specialty steps for patients enrolled in Ipsen Education Support) program pharmacy delivery CARES to receive their Somatuline provides free medication to eligible • At-home injection training for Depot savings: patients through its Patient As- caregivers, including adherence 1. Patient receives treatment with sistance Program. Ipsen CARES support Somatuline Depot. Physician will determine patient’s eligibility • Benefits verification and reim- follows standard procedure for for free product after the enroll- bursement support. collection of patient co-pay. ment process has been completed. 2. Provider submits claim to Patients can call 866.435.5677, Somatuline Depot patient’s insurance company. Monday through Friday, 8:00 Virtual Co-pay Savings 3. Patient and provider receive am to 8:00 pm EST, to begin the Program Explanation of Benefits (EOB) enrollment process. Patients can Patients who are enrolled in Ipsen statement; patient and/or also enroll online at: ipsencares- CARES and are beginning or physician mails or faxes EOB to portal.biologicsinc.com/login#Top currently receiving treatment with Ipsen CARES at 844.745.2532. or download the drug specific Somatuline Depot for an FDA- 4. Ipsen CARES program coor- enrollment form at: ipsencares. approved indication, who have dinator reviews EOB, faxes com/downloads/DEP00377%20 commercial insurance that covers Somatuline Depot card details Somatuline%20Patient%20 the medication and associated costs, to the provider. Financial%20Support%20 or are uninsured and paying their 5. Physician’s office uses the So- Application%20FINAL.pdf and fax entire out-of-pocket cost, may be matuline Depot card fax to pay the signed and completed form to eligible for the Somatuline Depot for the patient’s medication. 888.525.2416. Ipsen CARES offers Virtual Co-pay Savings Program. the following services for patients: Under this program patients pay NOTE: This program is not • Help at the start of therapy no more than $5 for up to an available to individuals enrolled • Financial assistance, including: $800 benefit. Program exhausts in federal or state subsidized co-pay assistance (referring after 12 months, 13 injections, healthcare programs that cover eligible patients to Somatuline® or a maximum benefit of $9,600, prescription drugs, including Depot Commercial Co-Pay whichever comes first. Patients Medicare (such as Medicare Part Program or an independent must enroll annually to receive a D prescription drug benefit),

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Medicaid, TRICARE, or any other Visit ipsencares.com for more federal or state healthcare plan, information. Questions? Call including pharmaceutical assis- 866.435.5677, Monday through tance programs. This offer is only Friday, 8:00 am to 8:00 pm EST. available in the U.S. and Puerto Rico, and is restricted in certain states. This offer may not be combined with any other coupon, discount, prescription savings card, Benefits Investigation Assessment Form free trial, or other offer. Patient Name REIMBURSEMENT ASSISTANCE Group Number Effective Date Insurer Insurer Phone # Ipsen CARES Ipsen CARES offers the following Insurer Website Reimbursement Assistance services to patients and providers: Deductibles Co-pay Amount (office visits, etc.) • Benefits Verification: Ipsen Co-Insurance CARES will help determine patient’s coverage, coverage Out-of-Pocket-Maximum Lifetime Maximum requirements, and co-payment or co-insurance amount Authorizations (Y/N): Scans • Prior Authorization: Ipsen MRI CARES will identify and communicate the specific infor- CT mation required by a payer to submit a prior authorization or PET exceptions request Chemotherapy • Appeals Support: Ipsen CARES will provide information on the Radiation payer specific process required to submit a level I or a level IMRT II appeal as well as provide IGRT guidance as needed throughout the appeals process. Pharmacy Benefits

In addition to Reimbursement Phone Number for Pharmacy Benefits Assistance, Ipsen CARES can Deductible connect providers with contact information to various distribu- Co-pay tors that can supply Somatuline Depot directly to their facility, Yearly Maximum and determine which in-network Lifetime Maximum pharmacy is best for a patient per insurance requirements and triage referrals.

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Janssen Biotech, Inc.

Oncology-related products: Darzalex™ (daratumumab), Doxil® (doxorubicin HCl liposome injection), Procrit® (epoetin alfa), Sylvant® (siltuximab), Yondelis® (trabectedin), Zytiga® (abiraterone acetate)

Patient and Reimbursement Assistance Website janssenprescriptionassistance.com

PATIENT ASSISTANCE program site so you can learn patients work together to fill more details about the program out and submit a program Janssen Prescription offerings and requirements application Assistance before you apply. The site’s • If approved, patients may This site can help providers: ultimate goal is to set you on a receive their medication either • Find available support pro- path toward finding the assis- directly from their healthcare grams. We have collected the tance you need from programs provider, at a local or mail available assistance programs for that are best suited to help you. order pharmacy using their Janssen products, and hope to Because living with disease can Pharmacy Card, or the medi- add more products in the future. be difficult. Paying for your cation will be mailed to their • Explain program require- medications shouldn’t be. home. How patients receive ments. Most financial assistance their prescription depends on programs require patients to Johnson & Johnson the medication prescribed. have a specific type of insurance Patient Assistance coverage to be eligible. The Foundation (JJPAF) Patients may be eligible for the programs listed on each drug This non-profit organization Johnson & Johnson Patient Assis- page can be filtered by the type provides free prescription medi- tance Foundation program if they: of insurance coverage patients cations to individuals who are 1. Are uninsured, or have been have to help narrow your focus. uninsured, or do not have adequate prescribed a medication not The site also lists as much as financial resources to pay for covered by insurance; some possible about other eligibil- their medication. The medica- Medicare Part D patients who ity criteria that each program tions are donated by the operating cannot afford their medications, requires, and the types of infor- companies of Johnson & Johnson, and who meet certain financial mation you will need to collect including Janssen Biotech, Inc. The criteria, may also be eligible for to complete an application. Foundation offers the following the program • Direct you to program applica- features: 2. Reside in the United States or a tions. In order to make sure the • One application for all products United States territory information on this site is timely • No fee to apply 3. Are being treated by a licensed and accurate, some informa- • Free medicines for up to one year U.S. doctor tion, like program applications, • Patients can reapply on a 4. Are being treated as an is not included. The site does yearly basis outpatient include direct links to each • Healthcare providers and 5. Meet the income eligibility for

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the products listed here: jjpaf. and news. By clicking on a product PROCRITline® org/eligibility/requirements.html. logo, providers can access drug- PROCRITline (janssenaccessone. specific reimbursement information. com/pages/procrit/patientassist/ Patients can either download the intro.jsp) offers services that health- enrollment form via the founda- DOXILine® care professionals can share with tion website at: jjpaf.org/resources/ DOXILine (janssenaccessone.com/ patients. Services include the jjpaf-application.pdf or call pages/doxil/index.jsp) is a suite PROCRITline Reimbursement 1.800.652.6227 to have an ap- of services designed to provide Hotline, which offers assistance with: plication faxed or mailed to them. reimbursement access and support • Benefit verification Completed applications should for patients and healthcare profes- • Prior authorization research and be faxed to: 1.888.526.5168. Or sionals. The DOXILine call center assistance mailed to: Johnson & Johnson provides access to reimbursement • Appeal process and procedure Patient Assistance Foundation, information and support, including: research Inc., Patient Assistance Program, • Benefit verification • Alternate sources of payment P.O. Box 221857, Charlotte, NC • Prior authorization research and • Catastrophic event handling for 28222-1857. assistance providers and patients • Appeal process and procedure • General billing and coding A provider portal (jjpafportal. research questions org) allows healthcare providers • Alternate sources of payment • Information regarding patient to manage their patients enrolled • General billing and coding assistance in the JJPAF Patient Assistance questions • Single point of contact. Program. Providers can submit ap- • Information regarding patient plications, check enrollment status, assistance. In addition, the PROCRITline track shipments, and perform website offers providers: important business functions that In addition, the DOXILine website • Billing and coding assistance would have otherwise have required offers providers: • A Medicare Announcements them to phone or fax the program. • Billing and coding assistance page, containing pertinent NOTE: Eligible hospitals may receive • A Medicare Announcements articles related to Medicare, medications to distribute directly to page, containing pertinent billing, electronic forms, and eligible outpatients via the Hospital articles related to Medicare, healthcare Access Patient Assistance Program. billing, electronic forms, and • An overview of key points More information about the eligi- healthcare of the Procrit reimbursement bility requirements can be found • An overview of key points of the process here: jjpaf.org/hcp/access.html. Doxil reimbursement process • ICD-10 Crosswalks as reference • A provider Toolkit with for the new ICD-10 codes Questions? Patient assistance examples of the documents that • Reference guides to the specialists are available at: are most often used to prepare a ICD-9-CM diagnosis codes 1.800.652.6227, Monday through payment claim • Key links to online healthcare Friday, 9:00 am to 6:00 pm EST. • Key links to online healthcare and reimbursement resources and reimbursement resources • Financial support resources to REIMBURSEMENT • Financial support resources to share with patients who have ASSISTANCE share with patients who have been prescribed Procrit. been prescribed Doxil. Accessone® Providers can also access This reimbursement portal Questions? Tel: 1.800.609.1083, PROCRITline Provider eSupport (janssenaccessone.com) offers Monday through Friday, 8:00 am that offers many of the same general reimbursement information to 8:00 pm EST. services as the PROCRITline

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Reimbursement Hotline. Additional eligible commercial patients to Monday through Friday, 8:00 am benefits include: assist them with their medica- to 8:00 pm EST. • Increased efficiency: providers tion out-of-pocket costs. Learn can review the status of all their more at: sylvant.com/shared/ ZytigaOne™ Support PROCRITline patients online product/sylvant/sylvant-patient- This website (janssenaccessone. • Timeliness: real-time access to rebate-program.pdf. com/pages/zytiga/index.jsp) patients’ enrollment status • Assistance with other cost provides healthcare providers and alerts support options, such as a and patients with easy access to • Flexibility: 24-hour access to patient assistance program for reimbursement information and patient accounts eligible uninsured patients. support including: • The ability to submit enroll- Learn more at: sylvant.com/ • ZytigaOne Support Patient ment forms electronically shared/product/sylvant/sylvant- Brochure (zytiga.com/shared/ • Secure messaging with cost-support-options.pdf. product/zytiga/zytiga-support- PROCRITline. • Access to educational patient-brochure.pdf) materials and information • ZytigaOne Support Provider To register, go to: oncologycare related to Sylvant. Brochure (zytigahcp.com/ pathportal.com, click “Register • Access to personalized appoint- shared/product/zytiga/zytiga- Now,” and complete the regis- ment reminders, which can help support-provider-brochure.pdf) tration process. Questions? Call patients remember their next • ZytigaOne Instant Savings 1.800.553.3851. scheduled appointment. Program Flashcard (zytiga. com/shared/product/zytiga/ SylvantOne™ Support Getting Started zytiga-instant-savings-card- SylvantOne Support (janssen 1. Complete a Business Associa- flashcard.pdf) accessone.com/pages/sylvant/index. tion Agreement as a one-time • ZytigaOne Support Enrollment jsp) offers healthcare professionals submission: sylvant.com/shared/ Form (zytigahcp.com/shared/ and patients reimbursement infor- product/sylvant/sylvant-busi- product/zytiga/zytiga- mation and support. ness-associate-agreement.pdf. prescription-enrollment-form- 2. For each patient appropriate english.pdf) Support for Providers for treatment with Sylvant, • A sample letter of medical • Investigation and assessment of complete a benefit investiga- necessity (zytigahcp.com/shared/ patient eligibility and coverage, tion form: sylvant.com/shared/ product/zytiga/zytiga-sample- plus concise benefit summary product/sylvant/sylvant-benefit- letter-of-medical-necessity.pdf) to physicians and staff investigation-form.pdf. • Specialty pharmacy information • Assistance with the prior 3. Fax the completed forms to (zytigahcp.com/shared/product/ authorization and appeal 1.855.299.8845. zytiga/zytiga-specialty-pharmacy- process as requested information-overview.pdf). This • Billing and coding information After receiving your complete is a list of specialty pharmacy • A personally-assigned benefit investigation form, Syl- provider phone numbers for SylvantOne Support Site vantOne Support will research you to use as a resource for Coordinator. your patient’s health coverage and therapy with Zytiga. return a verification of benefits • A business associate agreement Support for Patients within 48 hours. SylvantOne (zytigahcp.com/shared/product/ • Explanation of insurance Support will also attempt to reach zytiga/zytiga-business-associate- benefits and potential medica- your patient via telephone to agreement.pdf). Use this Janssen tion out-of-pocket expenses. review their benefits and discuss Biotech, Inc. Support System • Information on the SylvantOne potential cost support options. HIPAA Business Associate Agree- Patient Rebate Program for Questions? Call 1.855.299.8844 ment to be HIPAA compliant.

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Lilly Oncology

Oncology-related products: Alimta® (pemetrexed for injection), Cyramza (ramucirumab), Erbitux® (cetuximab) co-marketed with Bristol-Myers Squibb, Gemzar® (gemcitabine for injection), Portrazza™ (necitumumab)

Patient and Reimbursement Assistance Websites lillytruassist.com lillypatientone.com

PATIENT ASSISTANCE treatment with one less worry. Your If you have questions about patient uninsured, underinsured, or insured eligibility requirements, PatientOne Lilly TruAssist patients may qualify for the Patient program specialists are available Lilly TruAssist (lillytruassist.com) One Patient Assistance Program if Monday through Friday, 9:00 am is the collection of Lilly patient they meet eligibility requirements, to 7:00 pm EST. Call 1.866.4PatOne assistance programs that offer including: (1.866.472.8663). assistance to help people obtain • Patient is being administered the Lilly medicines they need. This a Lilly Oncology drug in the Uninsured Patients site includes all of Lilly’s patient United States. Lilly PatientOne may be able assistance programs with individual • Patient has proof of residency to connect qualified, uninsured program details. Finding programs in the U.S. or Puerto Rico. patients earning up to 500 percent that offer Lilly medicines for free is • Patient has no medical insurance of the Federal Poverty Level with easy with the Program Tool Finder: or the insurance does not cover a Lilly Oncology product at no lillytruassist.com/pages/Find therapy. If insured, patient must cost for ongoing therapy. (NOTE: Program.aspx. The finder tool have been denied coverage after Federal Poverty Level depends on allows patients and providers to two rounds of appeals. family size). If your patient has search for an appropriate program • Patient income is at or below been prescribed a Lilly Oncology one product at a time. Just answer a 500 percent of the federal product and meets the basic points few questions to see which program Poverty Level. (NOTE: Federal of eligibility: may be right for your patient. Poverty Level depends on family size.) 1. Download and complete the Lilly PatientOne • Patient is in ongoing therapy. Patient Assistance Program Lilly PatientOne (lillypatientone. • The date of service is within Application form: lilly com) addresses financial and 180 days of the date of applica- patientone.com/assets/pdf/ coverage issues for qualified tion approval. patient_assistance_program_ patients who are prescribed a Lilly • Treatment is or will be provided application.pdf. Oncology product. Through Patient in an outpatient setting 2. If applicable, also complete the One, you may be able to help your (provider is community-based Dosage Tracking form: lilly qualified patients get the assistance billing on CMS-1500 or outpa- patientone.com/assets/pdf/ they need, allowing them to start tient-facility billing on UB-04). dosage_tracking_form.pdf, and/

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 59 TABLE OF CONTENTS Lilly Oncology

or the Certification of Brand need including any available co-pay out the form be sure to check all Drug Usage form: program for the prescribed Lilly services that your patient might lillypatientone.com/assets/pdf/ Oncology product and the Patient need including Patient Assistance Certification_of_BrandDrug Assistance Program in case addi- Program, in the event your patient’s Usage.pdf. tional help is needed. Upon claim is denied. The treating 3. Once completed, fax the receipt of the application, Lilly physician will receive a response forms and proof of income to PatientOne may: from PatientOne on the patient’s 1.877.366.0585. • Assess the patient’s needs and application has been reviewed. 4. Once the application and appro- PatientOne’s ability to help Lilly PatientOne may: priate documentation have been • Conduct a benefits investiga- • Conduct a benefits investigation submitted and reviewed, you tion to help verify coverage and to assist in verifying coverage will be notified of your patient’s patient financial responsibility from the patient’s insurer. application status. If approved: for eligible products • Provide prior authorization • Eligible patients will be • Provide information on requirements for the patient’s enrolled into the Patient available co-pay assistance insurer. Assistance Program programs • Provide templates, forms, and • Approved dates of service • Refer you to a charitable checklists for filing an appeal will be determined based co-pay assistance foundation for denied claims for eligible on the submitted Dosage upon request. Lilly Oncology products. Tracking Form • Review the patient’s eligibil- These forms can also be found • Lilly Oncology may send ity for the Patient Assistance online: lillypatientone.com/ replacement vials for Program if additional help forms-library-patientone- ongoing therapy to your is needed. application.html. office for approved patients. • Upon request provide status • Lilly PatientOne may If your patient meets the eligibility updates for appeals that have evaluate the availability of requirements for the Patient As- been filed for eligible Lilly alternate funding options sistance Program, Lilly PatientOne Oncology products. if needed. may send replacement vials to your office for ongoing therapy. You may If the appeals process does not Learn more at: lillypatientone.com/ need to submit a Dosage Tracking result in a favorable decision, after financial-assistance-for-cancer- form, if applicable. If these addi- two levels of appeal have been patients.html. tional forms are required, please fax completed or all appeals have been them to 1.888.242.6230. exhausted, Lilly PatientOne will Underinsured Patients review the patient’s eligibility for Lilly PatientOne offers co-pay and Insured Patients the Patient Assistance Program. co-insurance assistance to eligible, Even if your patient is fully insured, You may need to submit a Dosage underinsured patients. For patients a claim may still be denied. Lilly Tracking form, if applicable. If who meet the eligibility require- PatientOne offers benefits inves- these additional forms are required, ments listed above, download and tigation and appeals assistance please fax them to 1.888.242.6230. complete a copy of the PatientOne to qualified, insured patients. If a application, or call 1.866.4PatOne patient’s claim is eligible, download Cyramza (1.866.472.8663) to request a and complete a PatientOne Co-pay Program copy of the application be sent application, or call 1.866.4PatOne With the Cyramza Co-pay Program to you. Fax the completed form (1.866.472.8663) to request a (cyramzahcp.com/resources/co-pay- to 1.877.366.0585. As you fill copy of the application be sent program.html), eligible patients can out the form be sure to check all to you. Fax the completed form lower out-of-pocket costs by paying services that your patient might to 1.877.366.0585. As you fill no more than $50 per infusion.

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(NOTE: Financial assistance is Maximum patient benefit: $42,000 REIMBURSEMENT limited to direct costs of Cyramza per 12-month period. Patients who ASSISTANCE and does not cover any additional continue Cyramza treatment and costs, including but not limited to wish to participate in the Cyramza Lilly PatientOne fees related to the administration of Co-pay Program must re-enroll Reimbursement Cyramza.) Eligibility criteria: every 12 months. Services • Age 18 years or older PatientOne offers resources that • Resident of the United States or Patient Enrollment Steps: may help your qualified uninsured, Puerto Rico 1. Review program eligibility with underinsured, and insured patients • Patients must be treated with your patient based upon the full obtain financial and reimbursement Cyramza for an FDA-approved criteria listed in the application. assistance including: indication 2. Download an application form: • Commercially insured patients lillypatientone.com/assets/pdf/ Insurance Expertise including patients enrolled in patient_assistance_program_ • Coding and billing information Health Insurance Exchange application.pdf or call Patient • Payment methodologies and Plans One at 1.866.4PatOne (1.866. allowables • Meet income cap criteria 472.8663) for a faxed copy. • Payer policy information. (program is restricted to those 3. Fax the completed applica- patients whose gross household tion to 1.877.366.0585, and Reimbursement Assistance income does not exceed the remind the patient to provide all • Eligibility determination greater of $100,000 or 500% of required documentation. Proof • Benefits investigation the Federal Poverty Level). of income required. Possible • Prior authorization documents to prove income: • Evaluation other funding Non-eligible: copy of W-2; or copy of prior options. • Participants in Medicaid, year tax return; or copy of Medicare, Medicare Part D, most recent pay stub; or copy Denied Claim Appeals Medigap, CAHMPUS, DoD, of social security check or • Appeals status if requested VA, TRICARE, or any state awards letter. • Denied claims appeals patient or pharmaceutical as- 4. Your patient’s application will templates, forms, and checklists. sistance program be reviewed to determine eligi- • Patients currently eligible for, bility pursuant to business rules. PatientOne program specialists are or enrolled in, a Lilly patient 5. Approved patients will receive available Monday through Friday, assistance program or another an enrollment letter and their 9:00 am to 7:00 pm EST. Call co-pay assistance program for co-pay card in the mail. 1.866.4PatOne (1.866.472.8663). Cyramza 6. Your office will be informed Learn more at: www.lillypatien- • Patients, pharmacists, and of patient’s enrollment status tone.com/. prescribers cannot seek through a faxed letter. (NOTE: reimbursement from health remind patients to bring their insurance or any third party co-pay card with them to their for any part of the benefit next appointment.) received by the patient through this offer. Questions? Call 1.866.4PatOne (1.866.472.8663).

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 61 TABLE OF CONTENTS Merck

Merck

Oncology-related products: Emend® (aprepitant), Emend® (fosaprepitant dimeglumine) for Injection, Intron® A (interferon alfa-2b, recombinant) for Injection, Keytruda® (pembrolizumab) for injection, for intravenous use, Sylatron™ (peginterferon alfa-2b) for Injection, Temodar® (temozolomide) available as capsules or for injection, Zolinza® (vorinostat)

Vaccine: Gardasil [Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18) Vaccine, Recombinant], Gardasil®9 (Human Papillomavirus 9-valent Vaccine, Recombinant)

Patient and Reimbursement Assistance Website merckaccessprogram.com

PATIENT ASSISTANCE free of charge to eligible individu- • Zolinza (vorinostat) 100 mg als, primarily the uninsured, who Capsules. Merck Access Program without assistance, could not afford The Merck Access Program can these needed Merck medicines. The Merck Patient Assistance help answer questions about access The Merck Access Program was Program offers temporary assis- and support, including: designed to help patients who tance to patients who generally • Insurance coverage for patients have been prescribed any of the meet the following requirements: • Reimbursement following Merck medicines: 1. They are a U.S. resident and • Co-pay assistance for eligible • Emend (aprepitant) 80 mg, have a prescription for a Merck patients 125 mg capsules medicine from a healthcare • Benefit investigations, prior • Emend (fosaprepitant dimeglu- provider licensed in the authorizations, and appeals mine) for Injection 150 mg United States • Referrals to the Merck Patient • Intron A (interferon alfa-2b, 2. They have no pharmaceutical Assistance Program. recombinant) for Injection, insurance coverage 10 million IU, 18 million IU, 3. They meet specified financial Contact the Merck Access Program 50 million IU criteria and cannot afford at 855.257.3932, Monday through • Keytruda (pembrolizumab) to pay for their medicine. Friday, 8:00 am to 8:00 pm EST. Injection [liquid formulation] Or download the enrollment form 100 mg NOTE: Individuals who don’t at: merckaccessprogram.com/static/ • Keytruda (pembrolizumab) for meet the insurance criteria may pdf/ONCO-1143560-0000.pdf and Injection 50 mg still qualify for the Merck Patient fax it to: 855.755.0518. • Sylatron (peginterferon alfa-2b) Assistance Program if they attest for injection, for subcutaneous that they have special circum- The Merck Patient use, 200 mcg, 300 mcg, 600 mcg stances of financial and medical Assistance Program • Temodar (temozolomide) hardship, and their income meets This program (merckhelps.com) Capsules 5 mg, 20 mg, 100 mg, the program criteria. provides certain Merck medicines 140 mg, 180 mg, 250 mg

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To enroll in the Merck Patient keytruda.com/static/pdf/merck- $63,720 or less for couples, or Assistance program visit access-program-keytruda- $97,000 or less for a family of merckhelps.com. This site will refer enrollment-form.pdf and fax it to: 4. (For income limits in Alaska them to the Merck Access site for Fax: 855.755.0518 or enroll online and Hawaii, please call 1.800. their specific medication, where at: merckaccessprogram-keytruda. 293.3881.) patients can begin the enrollment com/hcp/merck-access-program-key process, using the prescription truda-enrollment-form/. NOTE: Individuals who do not specific enrollment form. Questions meet the insurance coverage criteria about the Merck Patient Assistance NOTE: Co-pay assistance from the may still qualify for the vaccine Program? Call 1.800.727.5400, Merck Co-pay Assistance Program program if the patient has special Monday through Friday, 8:00 am is not insurance. Visit the Merck circumstances of financial and to 8:00 pm EST. Co-pay Assistance Program website medical hardship. (link above) for restrictions, terms, Co-Pay Assistance for and conditions. If your patient is Enrollment is Easy Keytruda deemed ineligible for the Merck 1. Complete and sign the applica- The Merck Co-Pay Assistance Co-pay Assistance Program for tion form. It is available online Program offers assistance to eligible Keytruda, a representative can at: merckhelps.com/docs/VPAP_ patients who need help affording provide you with information about Enrollment_Form_English.pdf Keytruda. Co-pay assistance may be independent foundations that may (English) and merckhelps.com/ available for patients who: be able to provide your patient with docs/VPAP_Enrollment_Form_ • Are at least 18 years of age financial support. Each independent Spanish.pdf (Spanish). Providers • Are a resident of the U.S. foundation has its own eligibility and their office personnel can (including Puerto Rico) criteria and application process. also call 1.800.293.3881 to • Have private health insurance obtain enrollment applications that covers Keytruda under a Vaccine Patient for patients and to request ad- medical benefit program Assistance Program ditional information about the • Have been prescribed Keytruda Patients who want to receive the program. for an FDA-approved indication Gardasil vaccine may be eligible 2. Fax the completed form to: • Meet financial eligibility criteria for the program if all three of the 1.800.528.2551 from a par- (To view the criteria visit: following conditions apply: ticipating licensed provider’s merckaccessprogram-keytruda. • Patients reside in the U.S. and office. The application must be com/hcp/the-merck-copay- are 19 to 26 years of age. submitted and approved prior assistance-program/) (NOTE: Patients do not have to to administration of vaccine • Meet all other terms and be U.S. citizens. Legal residents in order to qualify. Forms will conditions as outlined on the of the U.S. and U.S. territories be processed quickly—with a Keytruda co-pay assistance are also eligible to apply.) goal of less than 10 minutes website • Patients have no health insu- (between business hours of • Once enrolled, eligible, privately rance coverage. (Some examples 8:00 am-8:00 pm, ET, Monday insured patients pay the first of health insurance coverage through Friday)—and the $50 of their co-pay per infusion. include private insurance, provider’s office will be notified The maximum benefit under HMOs, PPOs, college health by phone so that qualifying this program is $25,000 per plans, Medicaid, veterans’ patients can receive the Merck patient per calendar year (based assistance, or any other social vaccine during that visit. on income). service agency support.) 3. A new application will need to • Patients have an annual be completed and submitted Download the Merck enrollment household income less than: to the Merck Vaccine Patient form at: merckaccessprogram- $47,080 or less for individuals, Assistance Program for eligibil-

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 63 TABLE OF CONTENTS Merck

ity assessment prior to a patient authorizations, and appeals • Refer patients to the Merck receiving a subsequent dose in a • Co-pay assistance for eligible Patient Assistance Program multi-dose series or for another patients • Answer questions about filling Merck vaccine. • Referrals to the Merck Patient out the enrollment form. Assistance Program for eligible REIMBURSEMENT patients (see details on this Contact the Merck Access Program ASSISTANCE program above). at 855.257.3932, Monday through Friday, 8:00 am to 8:00 pm EST. The Merck Access A dedicated representative may Or download the enrollment form Program be able to: at: merckaccessprogram.com/static/ This program (merckaccess • Research your patient’s pdf/ONCO-1143560-0000.pdf and program.com) can answers insurance benefits fax it to: 855.755.0518. questions about: • Obtain information on your • Insurance coverage for patients patient’s out-of-pocket costs • Reimbursement • Provide information on co-pay • Benefits investigations, prior assistance options

2016 Federal Poverty Guidelines

Family Size 100% 133% 138% 250% 400%

1 $11,770 $15,654 $16,242 $29,425 $47,080

2 $15,930 $21,186 $21,983 $39,825 $63,720

3 $20,090 $26,719 $27,724 $50,225 $80,360

4 $24,250 $32,252 $33,465 $60,625 $97,000

5 $28,410 $37,785 $39,205 $71,025 $113,640

6 $32,570 $43,318 $44,946 $81,425 $130,280

7 $36,730 $48,850 $50,687 $91,825 $146,920

8 $40,890 $54,383 $56,428 $102,225 $160,360

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Novartis Pharmaceuticals Corporation

Oncology-related products: Afinitor® (everolimus) tablets, Exjade® (deferasirox) tablets for oral suspension, Farydak® (panobinostat) capsules, Femara® (letrozole) tablets, Gleevec® (imatinib mesylate) tablets, Jadenu™ (deferasirox) tablets, Mekinist (trametinib) tablets, Odomzo® (sonidegib), Promacta® (eltrombopag) tablets, Sandostatin® (octreotide acetate) for injection, Sandostatin LAR® Depot (octreotide acetate for injectable suspension), Tafinlar (dabrafenib) capsules, Tasigna® (nilotinib) tablets, Tykerb® (lapatinib) tablets, and Votrient® (pazopanib) tablets, Zykadia™ (ceritinib) capsules

Patient and Reimbursement Assistance Websites hcp.novartis.com/access www.patientassistancenow.com

PATIENT ASSISTANCE hardship who have no third- bility program requirements are party insurance coverage for their 250% to 500% of the Federal The Novartis Patient medicines. To be eligible for the Poverty Level, depending on the Assistance Foundation Novartis Patient Assistance Fund, Novartis medicine. (See income This foundation (patientassistance patients must: chart below.) now.com/info/programsto • Be a U.S. resident. • Not have private or public accessmedicines/patientassistance • Meet income criteria, which prescription coverage. (NOTE: information.jsp) provides assistance vary by medication, and provide Exception process exists.) to patients experiencing financial proof of income. Financial eligi-

Table 1. Novartis Patient Assistance Foundation: Total Yearly Income Range

Household Size 250% Federal Poverty Level 300% Federal Poverty Level 500% Federal Poverty Level

General medicines and Transplant, antipsychotics, Oncology and multiple primary care medicines cystic fibrosis, hepatitis B sclerosis

1 Person $29,175 $35,010 $58,350

2 Person $39,325 $47,190 $78,650

4 Person $59,625 $71,550 $119,250

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Patients must reapply and re-qualify is right for your patient by calling needs to be completed if you annually. Questions? Contact the 1.877.577.7756 or by going to: believe the patient could be Novartis Patient Assistance copay.novartisoncology.com and eligible for the Patient Assistance Foundation at: 1.800.277.2254, clicking on the name of the medica- Program (PAP). For patient or go online to: patientassistance tion. This offer is not valid under assistance consideration, please now.com. Medicare, Medicaid, or any other attach proof of income, i.e., federal or state program. Novartis wage stubs, employer statement There are three ways to enroll in reserves the right to rescind, revoke, of income, tax returns, etc. the program: or amend this program without • Physician Information (Section • Enroll online by visiting: notice. Limitations apply. Read 4). Complete with all relevant pharma.us.novartis.com/info/ program terms and conditions at: information and best contact patient-assistance/patient- copay.novartisoncology.com. person. Be sure to sign the assistance-enrollment.jsp, Physician Authorization and and selecting the appropriate Patient Assistance Patient Assistance Program Novartis medication from the NOW Oncology (PAP) Consent for Physician drop down menu, and following (PANO) (if applicable). the instructions PANO (oncologyaccessnow.com) • Pharmacy Preference (Section • Call 1.800.277.2254 to enroll offers quick and easy access to in- 5). Choose your patient’s by phone. formation about our wide range of preferred pharmacy (if resources available to your patients. applicable). Novartis Oncology Enroll your patients into Novartis • Prescription Information Universal Co-Pay Card Oncology support programs by (Section 6). Please complete the Novartis Oncology created its completing this form: hcp.novartis. selected prescription informa- Universal Co-Pay Program (copay. com/globalassets/approved_ tion for your patient. Ensure novartisoncology.com) to help with onc-1112163-novartis-universal- that all necessary prescriber prescription costs for all the medi- enrollment-form-gsk-update- signatures are included. cations listed below: digital1.pdf. • Afinitor Fax completed forms to: • Exjade Follow the steps below to complete 1.888.891.4924. (NOTE: follow • Farydak the Novartis Service Request Form: instructions on enrollment form • Femara • Patient Information (Section for enrolling patients on Zykadia • Gleevec 1). Complete with all relevant and Farydak through a specialty • Jadenu information. Be sure to have pharmacy.) Questions? Call • Mekinist the patient sign the Patient 1.800.282.7630, Monday through • Odomzo Authorization and the Patient Friday, 9:00 am to 8:00 pm EST. • Promacta Assistance Program (PAP) • Sandostatin LAR Depot Consent for Patient (if appli- REIMBURSEMENT • Tafinlar cable). For Zykadia specialty ASSISTANCE • Tasigna pharmacy submission, patient • Tykerb signature is not mandatory. Patient Assistance • Votrient • Insurance Information (Section NOW Oncology • Zykadia 2). Please include a copy of the (PANO) front and back of the patient’s PANO (oncologyaccessnow.com) It’s simple to use and easy to find insurance card(s). helps patients and healthcare out if patients are eligible for the • Patient Financial Information providers with questions about program. Find out if this program (Section 3). This section only insurance verification and other

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reimbursement issues including, possible assistance for patients • Benefits investigations with insufficient medical benefit • Prior authorizations coverage or no drug coverage • Assistance with denials and and refer to other sources of appeals. funding that could help alleviate or reduce costs. Providers can download and • Referrals to patient assistance complete the Novartis Service for low-income uninsured Request Form at: hcp.novartis.com/ patients. globalassets/approved_onc-11121 • Help finding pharmacies 63-novartis-universal-enrollment- that stock Novartis medica- form-gsk-update-digital1.pdf and, tion. Program staff can also following the directions above, overnight an emergency supply, fax it to: 1.888.891.4924 (NOTE: and find other ways to get your follow instructions on enrollment patient their Novartis medicine. form for enrolling patients on • Letter of medical necessity. Zykadia and Farydak through a Through the hotline, copies specialty pharmacy.) Questions? of sample letters of medical Call 1.800.282.7630, Monday necessity are provided. through Friday, 9:00 am to 8:00 pm • Scheduled counselor appoint- EST. ments. Office practice managers can submit their questions and Oncology then schedule time to speak Reimbursement with a team of Novartis profes- Hotline sionals who will seek to provide By calling 1.800.282.7630, solutions to any problem. providers and patients can receive assistance in resolving reim- The Reimbursement Hotline and bursement issues and concerns, Novartis Pharmaceuticals Corpora- including: tion do not guarantee success in • Insurance verification. Program obtaining reimbursement, nor do staff verify patients’ medical they submit appeals on behalf of benefits, helps determine providers or patients. Third-party insurance coverage, and clarify payment for medical products and co-payment obligations. services is affected by numerous • Denials and appeals. factors, not all of which can be an- Program staff assist providers ticipated or resolved by Reimburse- in obtaining appropriate ment Hotline staff. reimbursement. • Coding and billing questions. Program staff can assist providers with questions regarding coding and billing. • Referrals to co-pay cards. • Alternative funding searches. Program staff can search for

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 67 TABLE OF CONTENTS Pfizer

Pfizer, Inc.

Oncology-related products: Aromasin® (exemestane tablets), Bosulif® (bosutinib) tablets, Camptosar® (irinotecan HCI injection), Ellence® (epirubicin hydrochloride injection), Emcyt® (estramustine phosphate sodium capsules, Ibrance® (palbociclib), Idamycin® (idarubicin hydrochloride for injection, USP), Inlyta® (axitinib) tablets, Neumega® (oprelvekin), Sutent® (sunitinib malate), Torisel® (temsirolimus) injection, Xalkori® (crizotinib) capsules, Zinecard® (dexrazoxane for injection)

Patient and Reimbursement Assistance Website pfizerrxpathways.com

PATIENT ASSISTANCE complete the Group B applica- • Meet certain income limits tion at: pfizerrxpathways.com/ that vary by medicine and Pfizer RxPathways sites/default/files/attachment/ house-hold size. For more than 25 years, Pfizer has PRxP_Application_Group_B_ • Live in the United States, Puerto offered a number of assistance pro- English_4.20.15_1.pdf. The Rico, or the U.S. Virgin Islands. grams to help eligible patients access application, along with any other • Be treated as an outpatient. their prescription medicines. Now, required documents should be to answer patients’ changing needs faxed to: 800.708.3430 or mailed After applying or contacting and make our services more acces- to: Pfizer RxPathways, P.O. Box Pfizer RxPathways, a Pfizer sible, we’ve combined our existing 66976, St. Louis, MO 63166-6976. RxPathways counselor will first programs into one program called work with uninsured patients Pfizer RxPathways. Formerly Pfizer If patients require immediate assis- to find and apply for insurance Helpful Answers, Pfizer RxPathways tance with their specialty medicines, options that may help them access is a comprehensive assistance pro- they or their prescribers should call their Pfizer specialty medicines gram that provides eligible patients 1.877.744.5675, Monday through (e.g., state pharmaceutical assis- with a range of support services, Friday, 8:00 am to 8:00 pm. tance programs, Medicaid, including insurance counseling, Medicare Part D, and low-income co-pay assistance, and access to To be eligible for free specialty subsidies). During this time, eligible medicines for free or at a savings. medicines, uninsured patients must: patients will be given up to a • Be prescribed a Pfizer specialty, 90-day supply of free medicine. Services for Uninsured Patients or “Group B,” medicine. To If eligible patients cannot secure Uninsured patients may be able view these medicines, click insurance coverage, they will to get certain specialty medicines “View Group B Medicine List” continue to get free medicine for free if they cannot secure on the Pfizer RxPathways through Pfizer RxPathways for insurance coverage. To apply for website (pfizerrxpathways.com). up to 12 months. free medicine, patients and their • Have no prescription coverage prescribers must download and to pay for their Pfizer medicines.

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Within two business days, patients with any other required documents. For more information on the eli- will be notified of their enrollment If patients require immediate assis- gibility requirements, application, status over the phone. If accepted, tance with their specialty medicines, and enrollment process, see the patients will then receive a letter they or their prescribers should call Group B application (pfizerrx containing their enrollment term 1.877.744.5675, Monday through pathways.com/sites/default/files/ and next steps on how to receive Friday, from 8:00 am to 8:00 pm attachment/PRxP_Application_ their free specialty medicine(s). For EST to start the process. Group_B_English_4.20.15_1. more information on the eligibil- pdf). Patients who participate in ity requirements, application, and After applying to or contacting any federal or state programs, enrollment process, see the Group Pfizer RxPathways, a Pfizer such as Medicaid or Medicare, are B application: pfizerrxpathways. RxPathways counselor will first not eligible for co-pay assistance. com/sites/default/files/attachment/ work with underinsured patients However, these patients may be PRxP_Application_Group_B_ to find and apply for other ways eligible to receive their medicine for English_4.20.15_1.pdf. to help patients with their co-pay. free through Pfizer RxPathways. Other sources of help could come Terms and conditions apply. Services for Underinsured from co-pay foundations, Medicare Patients Part D, low-income subsidies, and My Pfizer Brands If patients have prescription even co-pay card programs. If other My Pfizer Brands is a program for coverage, but still cannot afford funding cannot be secured, patients patients who want the brand-name their Pfizer specialty medicines, may be eligible to receive their product they’ve chosen with their they may be able to get them for Pfizer specialty medicines for free doctor. Many people, even those free. To be eligible for free specialty through Pfizer RxPathways. with prescription coverage, may medicines, patients without enough save with this program. Terms and health insurance coverage must: Within two business days, patients conditions apply. If the product • Be prescribed a Pfizer specialty, will be notified of their enroll- is available as a generic, patients or “Group B,” medicine. To ment status. If accepted, they will may pay less with other offers or view these medicines, click receive a letter that contains their by receiving the generic. Terms and “View Group B Medicine List” enrollment term and next steps on conditions apply. See full terms • Have prescription coverage, how to receive their free specialty and conditions on each respec- but not enough to pay for their medicine(s). Medicines will tive brand’s website. Card will Pfizer medicines typically be shipped to a patient’s be accepted only at participating • Meet certain income limits home, or to a prescriber’s office. pharmacies. Card is not health that vary by medicine and insurance. No membership fees. house-hold size In some cases, patients who apply Maximum annual savings of $400 • Live in the United States, Puerto for free medicine and have private to $10,000. For more information, Rico, or the U.S. Virgin Islands insurance coverage may instead call 1.866.341.9100 or write to • Be treated as an outpatient. receive co-pay assistance through Pfizer, PO Box 29387, Mission, KS Pfizer RxPathways. Instead of 66201-9618. To apply for free medicine, having free medicine shipped to patients and their prescribers must them, these patients will receive Regardless of income or employ- download and complete the Group a Pfizer RxPathways co-pay card ment status, patients may qualify B application (pfizerrxpathways. to use at their local pharmacy to for the My Pfizer Brands program if: com/sites/default/files/attachment/ cover the entire cost of their co-pay. • They pay for prescriptions with PRxP_Application_Group_B_ (NOTE: Pfizer RxPathways Co-Pay insurance at the pharmacy (this English_4.20.15_1.pdf) and mail or Assistance is not health insurance. means they are self-insured or fax it (see address and fax number For a complete list of participating have prescription coverage above) to Pfizer RxPathways along pharmacies call 1.877.744.5675.)

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 69 TABLE OF CONTENTS Pfizer

through their employer or their denied, Pfizer RxPathways videos, efficacy and safety infor- spouse’s employer) will investigate it and provide mation, and more, all of which • They pay out-of-pocket patients with information on can be viewed at your own pace (cash) for their prescriptions the appeals process. from either your desktop or at the pharmacy • Specialty pharmacy referral. tablet device. • They do not purchase pre- For patients prescribed Bosulif, • Epocrates® Online Premium is scriptions through Medicare, Ibrance, Inlyta, Sutent, or Xalkori an extensive database of brand Medicaid, or a federal or (crizotinib), Pfizer RxPathways and generic drug monographs, state program will refer them to a retail or searchable by name or class. • They are not a resident of a specialty pharmacy that will The peer-reviewed drug content state where this program is verify their benefits and help to is summarized from a wide prohibited by law. (Please check fill their prescriptions. range of authoritative sources. your brand’s website for specific Available on PfizerPro.com only, terms and conditions.) To receive insurance counseling for not as a PDF-download. (Inde- certain specialty medicines, patients pendent third-party resource.) To verify eligibility, select can call 1.877.744.5675, Monday • Get Healthy Stay Healthy is a brand-name product from those through Friday, 8:00 am to 8:00 pm consumer-focused health and listed in the keyboard located on EST. Patients can also download wellness site created with the the My Pfizer Brands home page and submit the Group B applica- help of a team of Pfizer medical (www.mypfizerbrands.com) then tion to begin the process. For professionals. Providers and click through to the available more information on the eligibil- patients will find videos, blog savings offer. If patients are not ity requirements, application, and posts, and interactive tools on eligible, there may be other ways enrollment process, see the Group a variety of topics, including they can save on their prescriptions B application: pfizerrxpathways. cancer, caregiving, arthritis, through Pfizer’s family of patient com/sites/default/files/attachment/ mental health, and more. assistance programs. Learn more at: PRxP_Application_Group_B_ • Grants and fellowships. Pfizer PfizerRxPathways.com. English_4.20.15_1.pdf. seeks to cooperate with healthcare delivery organiza- REIMBURSEMENT Pfizerpro.com tions and professional associa- ASSISTANCE PfizerPro www.pfizerpro.com( ) offers tions to narrow professional physicians the support they need to practice gaps in areas of mutual Insurance Counseling help improve their practice and interests through support of If insured or underinsured patients the lives of their patients, including: learning and change strate- need help understanding their • Clinical trial listings. Search the gies that result in measurable coverage and reimbursement database of ClinicalTrials.gov improvement in competence, options for certain Pfizer specialty for available clinical trials by performance, or patient medicines, Pfizer RxPathways can keyword, trial phase, location, outcomes. help by offering: and more. • Hispanic/Latino learning series • Reimbursement support. A • Digital product presenta- are PowerPoint presentations Pfizer RxPathways counselor- tions. These self-guided, online designed to educate healthcare will research and verify benefits, learning sessions are available professionals and other key outline coverage options for certain Pfizer products and stakeholders on cultural com- and policies, and explain the are designed to leave providers petency for Hispanic/Latino prior authorization process to with a clearer understanding populations. patients and their prescribers. of the Pfizer product discussed. • Pfizer medical information. • Appeals process information. The presentations feature case Have a medical question? If a claim is underpaid or studies, mechanism of action Submit a medical question, chat

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live about Pfizer prescription medicines, and more. Benefit Verification & Prior Authorization Checklist • Pfizer patient-reported outcomes is a resource for Does the patient’s insurance plan provide coverage for the drug under up-to-date versions and trans- a medical benefit or pharmacy benefit? lations of many available measures used to assess 3 Does the patient’s insurance plan require prior authorization patient-reported outcomes. It for the drug before initiation of therapy? offers current information on • What information does the patient’s insurance plan need validated measures developed for the prior authorization process? by Pfizer in various therapeutic areas, including CV/metabolic, • Typically, how long will the prior authorization process take? neuroscience, oncology, pain, sexual health, urology, and • Once obtained, how long will the prior authorization last women’s health. before another one is required? • Pfizer Responsible Disposal Advisor assists institutional • What are the patient’s cost-sharing responsibilities? facilities in properly disposing • What is the patient’s annual deductible? If the deductible of unused medicine. The site has not yet been met in full, how much is left? is now available to healthcare facilities and providers. Answers • What is the patient’s maximum out-of-pocket requirement? to your product disposal If the maximum out-of pocket has not yet been met in full, questions are only a click away. how much is left? • Pfizer samples. Eligible healthcare professionals can sign in 3 Does the patient have other non-primary sources of healthcare or register for PfizerPro, choose coverage, which need coordination of benefits with the from eligible samples or savings primary source? cards, and submit their requests. PfizerPro members can also call 3 Does the patient’s insurance plan have any coding or claims 1.888.736.8220 for more infor- submission guidelines which must be followed for reporting mation and to request samples. the drug and its administration? (NOTE: Not all Pfizer products 3 How much reimbursement does the patient’s insurance plan are available for sampling provide for the drug and its administration within the physician through this program.) office setting?

3 How much reimbursement does the patient’s insurance plan provide for the drug and its administration within the hospital outpatient setting?

Source. The ACCC Financial Advocacy Network. accc-cancer.org/FAN.

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Pharmacyclics, LLC

Oncology-related products: Imbruvica™ (ibrutinib)

Patient and Reimbursement Assistance Website imbruvica.com/youandi

PATIENT ASSISTANCE decision delays the YOU&i™ Start to 8:00 pm EST. Enroll online at: Program may be able to provide imbruvica.com/reg or download the YOU&i Access™ Instant access to Imbruvica. Eligible new enrollment form at: imbruvica.com/ Savings Program patients who have been prescribed docs/librariesprovider3/default- Patients with commercial insurance Imbruvica for an FDA-approved in- document-library/enrollment_form. and who meet eligibility require- dication, and who are experiencing pdf?sfvrsn=6. The Imbruvica ments will pay no more than $10 an insurance coverage delay greater YOU&i Support Program provides: per month for Imbruvica. (NOTE: than five business days, can receive • Rapid (2 business days) benefits Month refers to a 30-day supply. a free, 30-day supply of the drug. investigation Subject to a maximum benefit, If the decision delay persists, an • Information about the prior 12 months after activation or 12 additional free, 30-day supply may authorization process monthly fills [one-year supply], be provided. The free product is • Information about the insurance whichever comes first, unless the offered to eligible patients without appeals process maximum dollar benefit has been any purchase contingency or other • Help connecting to a specialty reached. Not valid for patients obligation. pharmacy (List of specialty enrolled in Medicare or Medicaid.) pharmacies can be found The program can also provide infor- REIMBURSEMENT here: imbruvica.com/docs/ mation on independent foundations ASSISTANCE librariesprovider3/default- that may be able to provide patients document-library/specialty_ with additional financial support. Imbruvica YOU&i™ pharmacies.pdf?sfvrsn=8). (NOTE: The Johnson & Johnson Support Program Patient Assistance Foundation, This personalized support program Nurse Call Inc. may be able to help uninsured from Pharmacyclics, Inc., and & Support Resources individuals who are unable to pay Janssen Biotech, Inc., includes In addition to the services outlined for their Imbruvica medication. information on access and afford- above, the Imbruvica YOU&i Contact a JJPAF program specialist ability, nurse call support, and Support Program offers informa- at 1.800.652.6227 from 9:00 am to resources for patients being treated tional phone calls with YOU&i 6:00 pm EST, or visit the foundation with Imbruvica. Healthcare Nurses about Imbruvica, ongoing website at jjpaf.org to see if your providers can help enroll patients tips, tools, and other resources patient might qualify for assistance. in this program before they start sent via email and text message, taking Imbruvica. For more infor- and Patient Starter Kits for new YOU&i™ Start Program mation, call 1.877.877.3536, Imbruvica patients. For patients experiencing coverage Monday through Friday, 8:00 am

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Sandoz, Inc.

Oncology-related product: Zarxio™ (filgrastim-sndz)

Patient and Reimbursement Assistance Website sandozonesource.com

PATIENT ASSISTANCE • Section 8: Patient consent/ Registration to provider portal will signature & financial informa- be available soon. Questions? Call Sandoz One Source™ tion. Complete only if you 844.SANDOZ1 (844.726.3691), Download an enrollment form believe the patient could be 9:00 am to 8:00 pm EST, Monday for patient assistance at: eligible for patient assistance. through Friday. sandozonesource.com. For patient For patient assistance consider- assistance program, complete ation, patients may sign consent Sections 1-6, and Section 8: for real-time income projector • Section 1: Patient information or may opt to include proof of • Section 2: Insurance informa- income documentation. tion. Include policy information for both your patient’s primary Registration to provider portal will and secondary insurance (as be available soon. Questions? Call applicable). It helps to include 844.SANDOZ1 (844.726.3691), a copy of the front and back of 9:00 am to 8:00 pm EST, Monday the patient’s insurance card(s). through Friday. If your patient has no insurance, check the “No Insurance” box. REIMBURSEMENT • Section 3: Treatment & ASSISTANCE prescribing information. Services currently available are a Attach prescription. coding flashcard and an enrollment • Section 4: Prescriber form for reimbursement assistance. information. Include office/ Both are available online at: primary contact person. sandozonesource.com. For reim- • Section 5: Patient authorization bursement assistance, complete & signature. Sections 1-7, listed above. • Section 6: Prescriber Reimbursement services include: authorization. • Benefit verification • Section 7: Commercial co-pay • Prior authorization assistance program. Skip this section if • Denials and/or appeals applying for the patient assis- information tance program.

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 73 TABLE OF CONTENTS Sanofi

Sanofi Oncology

Oncology-related products: Elitek® (rasburicase), Eloxatin® (oxaliplatin injection), Jevtana® (cabazitaxel), Leukine® (sargramostim), Mozobil® (plerixafor injection), Taxotere® (docetaxel injection), Thymoglobulin® (anti-thymocyte globulin [rabbit]), Zaltrap® (ziv-aflibercept) a collaboration between Sanofi and Regeneron Pharmaceuticals, Inc.

Patient and Reimbursement Assistance Website sanofipatientconnection.com

PATIENT ASSISTANCE Income Subsidy, 2) do not have to: Sanofi Patient Connection™, coverage for a generic equiva- PO Box 222138, Charlotte, NC Sanofi Patient lent, and 3) have out-of-pocket 28222-2138. Connection™ drug expenses of 5 percent This program can provide medi- of their household’s annual Sanofi Resource cation at no cost if patients meet income. For example, if their Connection program eligibility requirements. annual household income Sanofi Patient Connection offers a This component of the program is is $10,000, their individual unique service called Resource Con- made possible through the Sanofi out-of-pocket drug expenses nection (sanofipatientconnection. Foundation for North America. In would have to equal $500 com/resource-connection) in order to be eligible for the program, or more.) which program counselors work patients must meet the following • Must meet the following with patients and providers to requirements: financial criteria: 1) Annual determine if there are alternative • Must be a U.S. citizen or household income of ≤250% services available. Some examples resident and be under the care of the current Federal Poverty of different types of resources and of a licensed healthcare provider Level for all non-oncology/non- support that may be available authorized to prescribe, hematology products; 2) Annual include: dispense and administer household income of ≤500% • Clinical support services medicine in the U.S. of the current Federal Poverty • Nutritional supplements • Must have no insurance Level for all oncology/hematol- (groceries, food banks, etc.) coverage or access to the ogy products. • Transportation prescribed product or • Health supply/cosmetic aids treatment via your insurance. Download the application online (wigs, scarves, etc.) • Must not be eligible for at: sanofipatientconnection.com/ • Patient advocacy support Medicare or Medicaid. (Patients media/pdf/SPC_Application.pdf. • Home care services support who are enrolled in Medicare Questions? Call 1.888.VISITSPC (shelters, utilities, etc.). Part D may still be eligible for (1.888.847.4877), Monday through patient assistance if they meet Friday, 9:00 am to 8:00 pm EST. Download the Sanofi Patient all of these requirements and Completed applications can be Connection application at: 1) are not be eligible for Low faxed to: 1.888.847.1797 or mailed sanofipatientconnection.com/media/

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pdf/SPC_Application.pdf or the steps to get access: program brochure at: sanofi 1. Submit the registration form patientconnection.com/media/pdf/ 2. Talk to a provider portal SPC_Brochure.pdf. support team member • Upon receipt of your reg- REIMBURSEMENT istration request, the SPC ASSISTANCE Provider Portal Support Team will contact you Sanofi Patient via phone within one Connection to two business days to Sanofi Patient Connection validate and confirm your (sanofipatientconnection.com/ registration. reimbursement-connection) can 3. Create a user name and also help patients and providers password determine prescription insurance • Once step two is completed, coverage and options. Services you will receive an invita- include: tion email from the SPC • Insurance verification (benefits, Provider Portal Support deductibles, co-pay, and Team. The invitation email co-insurance verification) will contain a temporary • Prior authorization assistance password that is valid for • Coding and billing assistance two weeks. Within two • Claims management and weeks of receiving the appeals assistance. temporary password, log into the SPC Provider Portal Download the application at: (visitspconline.com), create sanofipatientconnection.com/media/ your user name, and convert pdf/SPC_Application.pdf. the temporary password to your own permanent The Sanofi Patient password. NOTE: If you Connection Provider are unable to convert the Portal temporary password to a The Sanofi Patient Connection permanent password within (SPC) Provider Portal (visits two weeks, you will be pconline.com) is an efficient and required to contact the SPC convenient tool for healthcare Provider Portal Support professionals and reimbursement Team (1.888.847.4877, personnel to enroll and manage option 4). their patients into the SPC suite of patient access services. This Need Additional Help with the secure, web-based provider portal Portal? The Provider Portal is available to give access to patient Support Team is available by case status updates, 24 hours a phone, Monday through Friday, day, 7 days a week. If you are 9:00 am to 8:00 pm ET at not already enrolled into the SPC 1.888.847.4877, option 4. Need Provider Portal, visit visitspconline. help with registering for access? com to register. Follow these simple Learn more at: visitspconline.com.

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 75 TABLE OF CONTENTS Seattle Genetics

Seattle Genetics

Oncology-related products: Adcetris® (brentuximab vedotin)

Patient and Reimbursement Assistance Website www.seagensecure.com

PATIENT ASSISTANCE each field is filled out completely NOTE: To be eligible for the and accurately to ensure timely Co-Insurance Assistance Program, SeaGen Secure™ processing of the application. If patients must have coverage for Patient Assistance you have any questions, please call Adcetris through a commercial Program 855.4SEAGEN (1.855.473.2436), insurer, be at least 18 years old, and SeaGen Secure offers a patient as- option 1, to speak with a reim- be seeking treatment for a labeled sistance program for uninsured and bursement counselor. indication. underinsured patients who have been prescribed Adcetris. Once an Benefits Investigation enrollment form (seagensecure.com/ Once the enrollment form is re- If patient does not have coverage assets/pdfs/SeaGenSecure_ ceived, a benefits investigation is for Adcetris: PatientAssist-BenefitsForm_EN_ conducted to determine an individ- • If the patient is insured, NEW.pdf) has been completed, fax ual patient’s coverage for treatment. SeaGen Secure will assist with it to: 855.557.2480. It is important It is SeaGen Secure’s priority to make an appeal. If the appeal is that each field is filled out complete- sure providers have patient-specific unsuccessful, the patient will ly and accurately to ensure timely coverage information before starting be assessed for eligibility for processing of the application. If patients on therapy with Adcetris, so patient assistance. you have any questions, please they will fax providers a summary • If the patient is uninsured, the call 855.4SEAGEN (855.473.2436), of the patient’s Adcetris-related patient will be assessed for option 1, to speak with a reim- benefits within two business days eligibility for the SeaGen Secure bursement counselor. of receiving the completed request. Patient Assistance program. If patient coverage for Adcetris is confirmed: REIMBURSEMENT Adcetris Co-Insurance • Refer to sample claims form ASSISTANCE Assistance Program (seagensecure.com/assets/ SeaGen Secure reimbursement SeaGen Secure offers an assistance pdfs/Sample_CMS_1500_ services include: program for commercially insured ADCETRIS.pdf) for billing • Billing and coding support. patients who have trouble affording guidance. Trained reimbursement counsel- their co-insurance. Once an en- • If patients need help paying ors provide payer-specific billing rollment form (seagensecure.com/ co-insurance, they will be and coding requirements to assets/pdfs/SeaGenSecure_Patient assessed for eligibility for the assist with the billing process. Assist-BenefitsForm_EN_NEW. SeaGen Secure Co-Insurance • Prior authorization assistance. pdf) has been completed, fax it to: Assistance Program or referred If it is determined that Adcetris 855.557.2480. It is important that to an independent foundation. treatment requires prior author-

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ization, SeaGen Secure can determine which forms and Tips for Filing Claims processes are needed to secure the authorization. Additionally, For Electronic Claims DO… SeaGen Secure can track the 3 prior authorization claim once Verify, file, and keep all transmission reports. it is submitted. 3 Track clearinghouse claims to ensure successful transmission. • Appeal assistance and claims tracking. If an Adcetris prior 3 Ensure your computer software is consistent with the clean authorization or claim is claims rules. denied (or partially paid), SeaGen Secure will work 3 Verify that your software correctly prints the CMS-1500 claim form. to determine the reason for 3 the denial and the steps for Call your software vendor, if needed, to address the above an appeal. SeaGen Secure two items. will also provide a sample For Paper Claims DO… Letter of Medical Necessity (seagensecure.com/assets/ 3 Use only original claim forms (printed in red drop-out ink). pdfs/ADCETRIS_Sample_ LMN_Appeal.pdf). Medical 3 Avoid folding claims, if possible. Information may be able to 3 assist with any additional data Resist using terms such as “refiled claim,” “second request,” requests. After SeaGen Secure or “corrected claim.” assists with an appeal and the 3 Avoid handwritten claims. documentation is submitted to the payer, they offer claims 3 Use all UPPERCASE letters. tracking to ensure the payer receives the appeal and 3 Stay inside the lines of each block. addresses it. Claims tracking 3 ensures that the provider is Ensure claims are printed darkly. aware of claims payment and/or For Paper Claims DON’T… any payer delays in processing. • General payer and policy 3 Use any punctuation or decimals. research. Many payers have established Adecetris policies. 3 Send unnecessary attachments. SeaGen Secure can provide a 3 copy of the requested policy Use staples or paperclips. or assist with navigating the 3 Attach “post-it” notes. Adcetris Payer Map. The Adcetris Payer Map allows 3 Mark up the claim with highlighters. providers to find payer policies based on their state and their 3 Use circles or additional markings. patient’s specific payer. 3 Attach labels or stickers.

3 Add notes or instructional assistance.

Source. The ACCC Financial Advocacy Network. accc-cancer.org/FAN.

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 77 TABLE OF CONTENTS Taiho Oncology

Taiho Oncology

Oncology-related product: Lonsurf® (trifluridine and tipiracil)

Patient and Reimbursement Assistance Website taihopatientsupport.com

PATIENT ASSISTANCE taihopatientsupport.com/Home/ • Specialty pharmacy ViewPef or Spanish at: taihopatient prescription coordination, Taiho Oncology support.com/Home/ViewPefSp including prescription Patient Support and fax the completed form to triage, coordination with the Taiho Oncology Patient Support 1.844.287.2559. Questions? Call in-network specialty pharmacy, offers the following services: 844-TAIHO-4U (844.824.4648) self-dispensing practice, or • Co-pay support for eligible, Monday through Friday, 8:00 am hospital retail pharmacy, and privately insured patients. to 8:00 pm EST. Or visit: claims appeals assistance if Such patients can receive a taihopatientsupport.com. coverage is denied. Taiho Oncology Patient Support • Personalized nurse support Co-pay Card for help with REIMBURSEMENT is available for treatment plan out-of-pocket expenses. ASSISTANCE adherence upon request. • Patient Assistance Program. Taiho Oncology Patient Support Taiho Patient Support will Taiho Oncology treatment plan adherence ser- research financial assistance Patient Support vices are available as needed to options for patients with no Taiho Oncology Patient Support support patient care, including insurance coverage, insuffi- will quickly investigate each refill reminders. cient prescription coverage, or patient’s coverage for Lonsurf insufficient resources to pay for and help them get access to the To enroll in Taiho Oncology treatment with Lonsurf. Eligible Lonsurf treatment they have been Patient Support simply download patients may receive Lonsurf prescribed. Taiho Oncology Patient the enrollment form in English at: at no cost based on assistance, Support offers the following services taihopatientsupport.com/Home/ financial, and medical criteria. to help improve access to Lonsurf, ViewPef or Spanish at: taihopatient • Alternate funding support. and to make the treatment process support.com/Home/ViewPefSp Taiho Patient Support will also as simple and smooth as possible: and fax the completed form to refer eligible, publicly insured • Access and reimbursement 1.844.287.2559. Questions? Call patients to nonprofit founda- support, including benefit 844-TAIHO-4U (844.824.4648) tions that may be able to offer investigations, assistance with Monday through Friday, 8:00 am them co-pay assistance. prior authorizations to meet to 8:00 pm ET. Or visit: To enroll in Taiho Oncology payer requirements, and claims taihopatientsupport.com. Patient Support simply download appeals assistance if coverage the enrollment form in English at: is denied.

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Takeda Oncology

Oncology-related products: Ninlaro® (ixazomib) capsules, Velcade® (bortezomib) for Injection

Patient and Reimbursement Assistance Websites ninlarohcp.com/1point velcade.com/Paying-for-treatment

PATIENT ASSISTANCE Application and a valid prescrip- fills of Ninlaro per enrollment tion for Ninlaro. Patients must year. This savings program covers Ninlaro 1Point sign the form and submit the out-of-pocket expenses greater This comprehensive support required household verification. than $25 per monthly prescrip- program offers an array of access If patients are approved for this tion. Maximum value $25,000 and coverage services for patients program, they and their doctor annually. Co-pay cards can be and their healthcare providers. will be notified and a 1-month renewed every 12 months. This A dedicated case management supply of Ninlaro will be mailed offer is not valid with any other team helps patients and providers to them. Each month, the provider program, discount, or incentive navigate coverage requirements for must confirm that the patient is involving Ninlaro. This offer may Ninlaro, streamline product access, still being treated with Ninlaro and be rescinded, revoked, or amended and connect to helpful resources. requires another month’s supply. without notice. No reproductions. Services include the: Qualified patients may be enrolled This offer is void where prohibited • Ninlaro Patient Assistance for up to 1 year. Get started or by law, taxed, or restricted. Get Program to learn more by calling 1.844. started or to learn more by calling • Ninlaro Co-Pay Assistance N1POINT (1.844.617.6468) 1.844.N1POINT (1.844.617.6468) Program and selecting option 2, Monday and selecting option 2, Monday • Ninlaro RapidStart Program. through Friday, 8:00 am to 8:00 through Friday, 8:00 am to 8:00 pm EST. Or download the enroll- pm EST. Or download the enroll- Ninlaro Patient ment form at: ninlarohcp.com/ ment form at: ninlarohcp.com/ Assistance Program downloads/Enrollment-Form.pdf downloads/Enrollment-Form.pdf The Ninlaro Patient Assistance and fax the completed form to: and fax the completed form to: Program provides free medication 1.844.269.3038. 1.844.269.3038. to eligible patients who do not have prescription drug or health Ninlaro Co-Pay Ninlaro RapidStart Program insurance coverage. If patients Assistance Program The RapidStart Program can qualify for the program, Ninlaro Eligible, commercially insured provide a 1-cycle (the number of will be delivered to them free of patients could pay as little as pills prescribed in a 28-day period) charge. To apply for the Patient $25 per monthly prescription supply of Ninlaro for patients who Assistance Program, providers must of Ninlaro. Patients must meet experience a delay in insurance submit a completed and signed eligibility requirements. This offer coverage determination of at least Patient Assistance Program is valid for up to 13 prescription 7 days. Terms and conditions

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 79 TABLE OF CONTENTS Takeda Oncology

apply. Physicians must submit a to: 800.891.9843. Learn more • Verify insurance and help with completed enrollment form and online at: velcade.com/Files/PDFs/ the prior authorization process a valid prescription. Get started VRAP_and_Patient_Assistance. and determining co-payment or to learn more by calling 1.844. pdf or by calling 1.866.VELCADE obligations. N1POINT (1.844.617.6468) (1.866.835.2233) and choosing • Research payer policies to and selecting option 2, Monday option 2. Dedicated case managers provide published policies for through Friday, 8:00 am to 8:00 are available Monday through both public and private payers. pm EST. Or download the enroll- Friday, 8:00 am to 8:00 pm EST. • Navigate the coding and billing ment form at: ninlarohcp.com/ process, including sample claim downloads/Enrollment-Form.pdf REIMBURSEMENT forms and tracking claim forms. and fax the completed form to: ASSISTANCE • Respond to claim appeals to 1.844.269.3038. help investigate underpayment Ninlaro 1Point or denial, contact insurers The Velcade Patient This comprehensive support regarding the appeal process, Assistance Program program offers an array of access assist in developing an appeal If patients do not have any and coverage services for patients strategy, and provide sample insurance coverage, they may be and their healthcare providers. A letters of medical necessity and eligible to participate in the Velcade dedicated case management team appeal. (NOTE: VRAP does Patient Assistance Program. If delivers personalized services not file claims or appeal claims, patients qualify for the program, that help patients and providers nor can it guarantee successful Velcade will be delivered free of navigate coverage requirements for reimbursement.) charge to their treating physician. Ninlaro, streamline product access, • Search for alternate funding to Patient eligibility is based on three and connect to helpful resources. help identify additional support factors: Services include: for uninsured and underinsured 1. Household income • Benefit verification and prior patients. 2. Treatment setting authorization assistance • Find supportive services, 3. Velcade prescribed for a use • Assistance with appealing including referrals for co-pays, that is medically appropriate. a payer denial transportation services, legal • Specialty pharmacy referral support, and national and local Patients who do not have insurance and coordination organizations for counseling. coverage for Velcade must apply for • Referral to alternative • Identify specific resources by assistance through their healthcare funding sources and state, county, or city where your professionals. To demonstrate eli- third-party foundations patient lives or receives therapy. gibility, they must complete an en- • Connection to support services, rollment form and provide income including referrals for transpor- The enrollment form is available documentation, as well as health tation services, legal support, online at: velcade.com/files/pdfs/ insurance information. It is strongly and national and local organiza- VELCADE_VRAP_Enrollment_ recommended that you enroll tions for counseling Form.pdf. Fax completed forms patients into the Patient Assistance • NINLARO RapidStart Program to: 800.891.9843. Learn more Program prior to the start of their for patients with insurance-related online at: velcade.com/Files/PDFs/ treatment with Velcade. All enroll- coverage delays. VRAP_and_Patient_Assistance. ment forms must be received within pdf or by calling 1.866.VELCADE six months of the first treatment. The Velcade (1.866.835.2233) and choosing The enrollment form is available Reimbursement option 2. Dedicated case managers online at: velcade.com/files/pdfs/ Assistance Program are available Monday through VELCADE_VRAP_Enrollment_ Dedicated (VRAP) case managers Friday, 8:00 am to 8:00 pm EST. Form.pdf. Fax completed forms help providers and patients:

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Resources for Healthcare Patient Assistance Checklist for Uninsured Patients Professionals 1. A Quick Reference Guide con- 3 I have received the chemotherapy order written by the physician? taining information for payer 3 I have met with the patient to assess his or her ability to pay for coding and payment informa- treatment? tion for Velcade: velcade.com/ 3 Based on this meeting, is the patient able to pay out-of-pocket for drug(s)? files/pdfs/QRG_PI.pdf. q YES q NO 2. Sample CMS-1500 Claim If no, list drug(s) below and continue on with checklist. Form: velcade.com/files/pdfs/ CMS-1500_withPI.pdf. 3 Is a replacement drug program available? q YES q NO 3. Sample CMS-1450 (UB-04) If yes, identify drug and program: Claim Form: velcade.com/files/ pdfs/CMS-1450_withPI.pdf. 3 Does the patient qualify for this program? q YES q NO 4. Sample Letter Supporting If no, state reason(s) why: Medical Necessity for Velcade: velcade.com/files/pdfs/Med 3 If yes, I have completed all the necessary forms and paperwork for the Necessity_withPI.pdf. drug replacement program. q YES q NO 5. Sample Letter Appealing a If no, state reasons why: Denied Claim for Velcade: velcade.com/files/pdfs/Appeal_ 3 Does the patient need drug(s) that are not available through a drug withPI.pdf. replacement program? q YES q NO 6. Sample Letter Appealing a If yes, identify which drugs: Denied Claim for Subcutaneous Injection: velcade.com/files/pdfs/ 3 Is Foundation funding assistance available for any of these drug(s)? NewSCLetter.pdf. q YES q NO If yes, identify Foundation(s) and drug(s): Learn more at: velcade-hcp.com/ reimbursement/Formslibrary.aspx. 3 I have completed all the necessary forms and paperwork for these Foundation funding program(s). q YES q NO If no, state reasons why:

3 Does the patient qualify for charity care within from my clinic, cancer center, hospital, or healthcare system? q YES q NO If yes, identify program:

3 I have completed all the forms and paperwork necessary to apply for this charity care. q YES q NO If no, state reasons why:

3 Is there a balance or money owed related to treatment? q YES q NO If yes, identify balance:

3 If yes, I have worked with the patient and family to create a payment plan for the balance of his or her treatment costs. q YES q NO

Source. The ACCC Financial Advocacy Network. accc-cancer.org/FAN.

ACCC 2016 Patient Assistance and Reimbursement Guide I accc-cancer.org / 81 TABLE OF CONTENTS TEVA Oncology

TEVA Oncology

Oncology-related therapeutic products: Bendeka™ (bendamustine hydrochloride) for Injection Synribo® (omacetaxine mepesuccinate) for Injection; Treanda® (bendamustine HCl) for Injection, Trisenox® (arsenic trioxide) for Injection

Oncology-related supportive care products: Actiq® (oral transmucosal fentanyl citrate) [C-II], Fentora® (fentanyl buccal tablet) [C-II], Granix™ (tbo-filgrastim) injection

Patient and Reimbursement Assistance Websites tevacares.org tevacore.com

PATIENT ASSISTANCE reimbursement assistance program Monday through Friday, to provide or other type of program to assist assistance with the following: The Teva Cares you. For more information, please Foundation call 888.TEVA.USA (838.2872). • Benefit verification and coverage The Teva Cares Foundation Patient Some patients may be eligible for determination Assistance Programs provide certain assistance from other programs. For • Pre-certification and prior autho- Teva medications at no cost to a listing of these other assistance rization support patients in the United States who programs go to: tevacares.org/ • Coverage guidelines and claim meet certain insurance and income OtherResources.aspx. requirements of payers criteria. Eligibility is based on a • Personalized support through patient’s income and prescription REIMBURSEMENT the claims and appeals process insurance status. To determine if ASSISTANCE • Templates for letters of medical your patient qualifies, review the necessity Teva Cares Foundation Patient CORE • Identify programs that may be Assistance Programs eligibility CORE (Comprehensive Oncology able to assist patients with costs requirements online at: tevacares. Reimbursement Expertise) provides associated with their treatment org/DoIQualify.aspx or call patients and providers with a reim- • Teva Cares Foundation, the 877.237.4881, Monday through bursement support program, as Teva Oncology Patient Assis- Friday, 9:00 am to 8:00 pm EST. well as online tools to help make it tance Program. Then download the enrollment easier to understand and navigate application at: tevacares.org/Down reimbursement. The CORE Hotline Download the CORE enroll- loadApplication.aspx and fax it to: (1.888.587.3263) is a service ment form at: tevacore.com/PDF/ 877.438.4404. provided by Teva Oncology to help Enrollment%20Form.PDF. Fax the physicians and their patients under- completed form to 866.676.4073. If your patient does not meet the stand the complexities of reim- Providers can also create an eligibility requirements for the Teva bursement and where CORE fits account and enroll their patients Cares Foundation Patient Assis- in. Reimbursement consultants are online at: https://eprescribe.iassist. tance Programs, Teva may offer a available 9:00 am to 8:00 pm EST, com/?style=tevaoncology.

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Other Patient Assistance Programs & Resources

Agingcare.com • Utilities CancerCare® agingcare.com • Legal cancercare.org • Healthcare expenses A web-based resource for caregiv- • Housing expenses CancerCare provides limited finan- ers, including the Prescription Drug • In-home services cial assistance to people affected Assistance Locator: agingcare.com/ • Taxes by cancer. As a non-profit orga- Articles/prescriptiondrugassistance- • Transportation nization, funding depends on the program-locator-171753.htm. This • Employment training. sources of support CancerCare tool allows older adults and their receive at any given time. If families to search for financial aid If patients have Medicare and have CancerCare does not currently programs for prescription medica- limited income and resources, they have funding to assist you, their tions. Search for prescription drug may be eligible for the Medicare professional oncology social assistance plans by state or medi- Rx Extra Help program. Patients workers will always work to refer cation name or browse a list of may be able to get extra help pay- you to other financial assistance nationwide non-profit prescription ing for prescription drug costs if: resources. Check: cancercare.org drug assistance programs. • Their income is less than periodically for funding updates. $17,655 (if single) and $23,895 In order to be eligible for financial BenefitsCheckUp® (if married). If they live in assistance patients must: benefitscheckup.org Alaska or Hawaii, they may still • Have a diagnosis of cancer get help even if their income is confirmed by an oncology A free service of the National higher than these limits. healthcare provider Council on Aging (NCOA), a non- • Patients have resources less than • Be in active treatment for cancer profit service and advocacy organi- $13,640 (if single) and $27,250 • Live in the U.S. or Puerto Rico zation. Many adults over 55 need (if married). • Meet our eligibility guide- help paying for prescription drugs, lines of 250% of the Federal healthcare, utilities, and other basic If patients meet the guidelines, they Poverty Limit. needs. There are over 2,000 federal, will have low or no deductibles, state, and private benefits programs low or no premiums, no coverage Here’s how to apply: available to help. BenefitsCheckUp gap, and will pay much less for 1. Call 800.813.HOPE (4673) and asks a series of questions to help prescriptions. At the same time, speak with a CancerCare social identify benefits that could save pa- patients can start the application worker to complete a brief tients money and cover the costs of process for the Medicare Savings interview, 9:00 am to 7:00 pm everyday expenses. After answering Programs that could increase their ET, Monday through Thursday, the questions, patients receive a per- monthly income by about $105. and 9:00 am to 5:00 pm ET sonalized report that describes the Patients will also find out if there on Friday. programs that may help them. are other benefits programs that 2. If patients are eligible to apply, Patients can apply for many of the can save them money. Apply online we will: programs online or print an appli- at: www.benefitscheckup.org/cf/ • Mail you an individualized cation form. Here are the types of continue.cfm. For more information bar coded application expenses patients may get help with: go to: benefitscheckup.org. • Request documentation to • Medications verify your income. • Food

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3. Patients must submit a com- education, and financial assistance sign our physician verification pleted application. Here are with treatment-related expenses form. Patients must currently some tips: such as transportation and be undergoing chemotherapy • Print clearly—illegible appli- child care. or prescribed and/or using a cations cannot be processed. targeted treatment drug when • Fill in each blank space In order to be eligible for assistance, they apply to CCAF, and at the in the application. Use patients must complete and sign time of approval. “no,” “none,” or “0” as an application and HIPAA Authori- • Insurance. Patients must be appropriate—do not leave zation form, as well as provide covered by private insurance any blank responses. proof of income. CCAF will review or an employer-sponsored • Have a medical oncology your application and forms on a health plan, or they must have healthcare provider first-come, first-served basis to the Medicare Part B, Medicare Part complete all sections of the extent that funding is available. D, or a Medicare Advantage Medical Information Section Plan (Medicare C). and provide a signature NOTE: as a non-profit organiza- and date. Patients cannot tion, CCAF cannot guarantee that NOTE: if patients have private complete this section. funding will always be available insurance, please contact the drug • Make sure patients use the for a particular diagnosis. If unable company that manufactures their correct CancerCare mailing to provide co-payment assistance, medication before you contact address and fax number however, they will refer you to CCAF. Patients who are uninsured listed on the application. other organizations that may be (do not have any insurance or able to help. medical plan that covers their pre- NOTE: CancerCare’s financial scription medicines), are not eligible assistance does not cover basic To qualify for assistance, patients for co-payment assistance. However, living expenses such as rent, mor- must meet the criteria below: we encourage you to contact us at: tgages, utility payments, or food. • Financial. Individuals or 866.55.COPAY (866.552.6729), families with an adjusted gross 9:00 am to 7:00 pm EST, Monday CancerCare® income of up to four times through Thursday, and 9:00 am to Co-payment Assis- the Federal Poverty Level may 5:00 pm on Friday, so that we can tance Foundation qualify for assistance. CCAF refer you to other organizations or cancercarecopay.org may also consider the cost of patient assistance programs. living in a particular city or CCAF helps people afford the cost state. Income verification is • Other criteria. Patients must of co-payments for chemotherapy required as part of the applica- be receiving treatment in the and targeted treatment drugs. This tion process. Patients must have United States. Patients must be assistance is provided free of charge private insurance or Medicare a U.S. citizen or legal resident. to ensure patient access to care and that covers a portion of the compliance with prescribed treat- prescribed chemotherapy or Eligible individuals will receive an ments. CCAF offers a seamless, targeted treatment. application packet with instruc- same-day approval process through • Medical. Patients must be tions on how to apply for assis- a state-of-the-art online platform. diagnosed with one of the tance. Co-payment specialists are This allows immediate access to the cancer types covered by CCAF. available to answer questions about full array of CancerCare support The treating physician must this process. Or patients can enroll services, including telephone, submit a verification form online at: http://portal.cancercare online, and in-person counseling, confirming diagnosis and copay.org. CCAF provides easy support groups, information and medications. In addition, the access to enrollment and can resource referrals, publications, physician must complete and provide same-day approval.

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Cancer Financial requires relative to their diagnosis. the Provider Online Application Assistance Coalition CPR call counselors work directly Portal available 24 hours a day: cancerfac.org with the patient as well as with the copays.org/providers. provider of care to obtain necessary 3. Pharmacies may apply on CFAC is a coalition of financial medical, insurance and income behalf of their patients via the assistance organizations joining information to advance the ap- Pharmacy Online Application forces to help cancer patients expe- plication quickly. Upon approval, Portal available 24 hours a day: rience better health and well being payments may be made to: copays.org/pharmacy. by limiting financial challenges, • The pharmacy 4. The program offers personal through: • The healthcare provider service to all patients through 1. Facilitating communication and • The patient directly. the use of an Application collaboration among member Specialist, personally guiding organizations Eligibility requirements: patients through the enroll- 2. Educating patients and • Patients must be insured and ment process toll free at providers about existing insurance must cover the 866.512.3861, Option 1. resources and linking to other medication for which they seek organizations that can dis- assistance. HealthWell Foundation seminate information about • Patients must have a confirmed healthwellfoundation.org the collective resources of the diagnosis of the disease or member organizations illness for which they seek The HealthWell Foundation reduces 3. Advocating on behalf of cancer financial assistance. financial barriers to care for under- patients who continue to • Patients must reside and receive insured patients with chronic or bear financial burdens associ- treatment in the United States. life-threatening diseases by ated with the costs of cancer • The patient’s income must fall providing financial assistance to treatment and care. below the income guidelines of eligible individuals to cover the the fund under which they are cost of co-insurance, co-payments, Because CFAC is a coalition of requesting financial assistance. healthcare premiums, and deduct- organizations, it cannot respond to All funds have income guide- ibles for certain medications and individual requests for financial as- lines of either 300 percent, 400 therapies. If patients have some sistance. To find out if financial help percent, or less of the Federal healthcare coverage, either through is available, use the CFAC database Poverty Guideline with consid- a private insurance plan or a federal at: cancerfac.org. Search by cancer eration of the Cost of Living or state-funded program such as diagnosis or specific type of assi- Index and the number in the Medicare or Medicaid, but still stance or need (i.e., general living household. cannot afford the out-of-pocket expenses, transportation, childcare). costs associated with their medical NOTE: Patients will be informed treatment, HealthWell may be able Co-Pay Relief immediately upon application if to help. copays.org they qualify for assistance. With the patient’s permission, The Patient Advocate Foundation The CPR Program offers four providers and patient advocates (PAF) Co-Pay Relief Program (CPR) points of entry: can apply on behalf of a patient provides direct financial support to 1. Patients may apply via the in two ways: qualified patients, including those Patient Online Application 1. Apply online at: grants. insured through federally adminis- Portal available 24 hours a day: healthwellfoundation.org/ tered health plans such as Medicare, copays.org/patients. patients/apply assisting them with prescription 2. Medical providers may apply 2. Apply by phone at: drug co-payments their insurance on behalf of their patients via 800.675.8416.

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Before beginning the application on the type of assistance requested co-pay obligations. LLS can also process, have the following infor- and instructions for submitting help providers and patients find mation ready: the reimbursement OR a pharmacy additional sources of financial 3 Patient contact information card (fund appropriate). In ad- support. The LLS Co-Pay Assis- (name, address, telephone dition, HealthWell will fax a copy tance Program offers financial help number, social security number, of the approval letter to the pro- toward: date of birth). vider as long as their fax number • Blood cancer treatment-related was provided. co-payments NOTE: If patient does not have a • Private health insurance social security number, providers NOTE: The HealthWell Founda- premiums should call 800.675.8416 to speak tion randomly selects patients for • Medicare Part B, Medicare Plan with a HealthWell representative. income audits and confirmation of D, Medicare Supplementary diagnosis. Individuals applying on Health Insurance, Medicare 3 Patient insurance and prescrip- behalf of a child for the pediatric Advantage premium, Medicaid tion information and ID (i.e., assistance fund will not receive spend-down, or co-pay insurance and pharmacy card) immediate grant approval. For obligations. 3 Patient income information more information on the Pediatric (total household income, total Assistance Fund application process To be eligible for Co-Pay Assistance, household size) visit: healthwellfoundation.org/ patients must: 3 Prescribing physician informa- pediatric-assistance-fund. 3 Have a household income at or tion (name, address, telephone below 500 percent of the U.S. number, fax number, and When a patient applies and is Federal Poverty Guidelines as contact name) approved for assistance, the grant adjusted by the Cost of Living 3 Fund to which the patient is start date can be up to 30 days Index applying for assistance prior to the application date. All 3 Be a United States citizen or 3 Type of assistance the patient active grant recipients are welcome permanent resident of the U.S. is applying for co-pay or to re-enroll at the end of their grant or Puerto Rico and be medically premium. cycle (one year) as long as assistance and financially qualified is still required and the individual 3 Have prescription insurance NOTE: not all funds offer premium still meets the program criteria and coverage assistance. funding is available. Patients can 3 Have an LLS Co-Pay Assis- begin the re-enrollment process up tance Program covered blood The HealthWell Foundation pro- to 30 days prior to the end of their cancer diagnosis confirmed by vides instant approval for patients current enrollment period. a provider (See a list of covered applying online or via phone. diagnoses here: http://www.lls. (Online applications can take up Questions? Call 800.675.8416 org/support/financial-support/ to one business day to process; to speak with a HealthWell co-pay-assistance-program. patients and providers who apply representative. over the phone can expect to know Apply online at: of their approval status within The Leukemia & • Providers: sx2035.unicentric. 10 to 15 minutes.) If approved, Lymphoma Society com/llsportal/ForProviders.aspx HealthWell will send an approval lls.org • Patients and caregivers: sx2035. letter with the enrollment period unicentric.com/llsportal/For dates and grant amount to the The Leukemia & Lymphoma Patients.aspx. patient. The approval letter will Society (LLS) Co-Pay Assistance provide the patient with a Reim- Program helps patients pay their You can also apply or get more bursement Request Form based insurance premiums and meet information about the LLS Co-Pay

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Assistance Program, by calling Applications Assistance: program about which you want 877.557.2672 and speaking with a If you need help filling out your more information, you can also co-pay specialist who will provide applications, see our list of organiza- search by name of program. personalized service throughout the tions that provide application assi- application process. stance for free or a small fee here: Assistance with needymeds.org/local_ programs.taf. Government Programs: NeedyMeds These organizations can help with Every state has programs to help needymeds.com such things as finding a program needy families and individuals with for your prescription medication, the cost of healthcare. NeedyMeds Programs called Patient Assistance completing the application forms, has compiled a database of these Programs (PAPs), which are created and working with physicians who state programs. The programs can by pharmaceutical companies, must sign the forms. You can find be found by visiting: needymeds. provide free or discounted medicine local programs in two ways: org/state-programs, and clicking on to people who are unable to afford 1. Enter the patient’s zip code to a state, the District of Columbia, the medications they have been find a program in their area or Puerto Rico, or Guam. Programs prescribed. Each program has its 2. Search by state. and their guidelines vary from state own qualifying criteria. To find to state. NeedyMeds also has a a PAP that you may qualify for If your medicine does not appear on state-by-state list of Medicaid sites: click on the brand name drug here: the brand name or generic name lists, needymeds.org/medicaid, as well as needymeds.org/brand-drug then it is not available through a PAP. general information on Medicare: or generic name drug here: Other assistance options include: needymeds.org/medicare-info. needymeds.org/generic-drug. Then: • Diagnosis-Based Assistance: 1. Click on the first letter of the needymeds.org/copay_branch.taf. For all help line questions, send name of your medicine in the There are many government and emails to [email protected] alphabet bar. private-funded programs that or call our toll-free number: 2. Click on the name of your help with costs associated with 1.800.503.6897. medicine to access the eligibility a specific diagnosis. They may and contact information for the cover many types of expenses, Partnership for program(s). In some cases, the including drugs, insurance Prescription Assistance program application form can co-pays, office visits, transporta- pparx.org be printed from our website. tion, nutrition, medical supplies, Applications should be faxed or child, or respite care. Some cover The Partnership for Prescription mailed directly to the PAP, not one specific diagnosis, while Assistance (PPA) helps qualify- to NeedyMeds. others cover whole categories ing patients without prescription 3. PAPs can also be found by (such as all types of cancers) or drug coverage get the medicines looking through the Program even all chronic medical illnesses. they need for free or nearly free by Name List found here: Some programs are national in matching them with the right assi- needymeds.org/program-list scope, while others are limited stance programs. The Partnership OR by looking through to people in specific states. Most for Prescription Assistance will help the Company Name List: have some type of eligibility you find the program that’s right http://www.needymeds.org/ requirements, usually financial for your patient, free of charge. company-list. ones. It’s best to search by the 4. If an application form is available type of diagnosis. Other ways Step 1. Tell us what medicines your through a PAP, look for it in the to search for assistance are by patient takes. Go to: www.pparx. Program Applications list. Look looking for programs that serve org/gethelp/select-therapies. Type for all of your medications, not a specific geographical area. If the name of the medicine into the just the most expensive ones. you know the name of a specific box and click the search button.

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Once the search is complete you programs/savings_cards • Check claims can add one or more prescription • Information about Medicare • Check payment status drugs from your search to the My drug coverage at: pparx.org/ • Access patient approval letters Medicines list, which appears on prescription_assistance_ that state the amount of assis- the right side of the page. Repeat programs/medicare_drug_ tance patients qualify for this process until you have entered coverage • Send to and receive secure and selected all of the medicines. messages from PAN case Have recent natural disasters managers about specific patients Step 2. Tell us about your patient. affected your patient’s ability • Attach a physician’s electronic Provide basic information about to get access to their prescrip- signature to online PAN the patient and the type of drug tion medicines? Download the applications. coverage (if any) he or she currently natural disaster worksheet: pparx. has. Answer short questions, such org/sites/default/files/Natural%20 In order for patients to qualify for as the patient’s residency, age, and Disaster%20Worksheet_Final.pdf co-payment assistance with the household income, to see which and PPA may be able to match your Patient Access Network Founda- patient assistance programs they patient with a program to help them tion, they must meet the following may qualify for. You must answer regain access to their medicines. eligibility criteria: all questions on this page for your • Patient is insured and insurance patient to be considered. If you need Patient Access Network covers the medication for which assistance, please call 1.888.477.2669 Foundation the patient seeks assistance Monday through Friday, from 9:00 panfoundation.org • The medication must treat the am to 5:00 pm EST. disease directly The Patient Access Network • Patient’s income must be Step 3. Get your patient’s results. Foundation (PAN) facilitates below a designated percentage See which prescription assistance access to medical treatment for of the Federal Poverty Level, programs your patient may be patients with chronic, rare, or depending on individual fund eligible for and select the ones you life-threatening illness. Since 2004 requirements would like to apply to. PAN has awarded hundreds of • Patient is prescribed a high-cost millions of dollars in financial drug for the disease, depending Step 4. Complete the application assistance to patients in need. on program specific guidelines process. Print, complete, and mail Providers and their patients can • Patient must reside and receive applications to each program your apply for assistance by calling treatment in the U.S. (U.S. citi- patient is applying to. You may 1.866.316.7263, between 9:00 zenship is not a requirement.) download the applications directly am and 5:00 pm ET or start the from your computer or device or application online through the Pan Step 1. Log into the correct Pan have them emailed to you. Foundation Provider Portal: https:// Foundation Portal (i.e., “Provider providerportal.panfoundation.org/. Portal,” “Patient Portal,” or PPA offers other resources, “Pharmacy Portal”) to begin the including: In addition to enabling providers to application process. • A list of Patient Assistance enroll on their patients’ behalf, the Programs: pparx.org/ provider portal allows healthcare Step 2. Select the fund name in prescription_assistance providers to: which you are applying for assi- _programs/list_of_ • Access patient’s profile that stance. Then, select the name of participating_programs contain patient account in- the medication for which you are • A list of discount drug card formation, claims status, applying for assistance. programs at: pparx.org/ payments, etc prescription_assistance_

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Step 3. You will need to access Foundation Portal. For more infor- threatening disease. Call toll free at to the following information for mation or to apply over the phone 1.800.532.5274. the patient: call 1.866.316.7263, between 9:00 Demographic information am and 5:00 pm EST. MedCareLine program. The • First and last name MedCareLine is a division of • Social Security number or Patient Advocate Patient Advocate Foundation Alien Number Foundation staffed with a team of nurses and • Phone number patientadvocate.org case managers who provide individ- • Street address and email ualized case management services address. The Patient Advocate Founda- to a specific population of patients, Income Information tion (PAF) is a national non-profit caregivers, and providers. • Tax forms (1040, 1040 EZ) organization that provides profes- • Social Security statements (1099) sional case management services Financial aid fund division. This • Retirement income documenta- to Americans with chronic, life independent division of Patient tion (e.g., IRA and pensions) threatening, and debilitating Advocate Foundation provides • Other income sources (e.g., illnesses. PAF case managers, small grants to patients who meet alimony, child support, rental assisted by doctors and health- financial and medical criteria. income) applicable to the care attorneys, serve as an active Grants are provided on first-come patient and all members of the liaison between the patient and first served basis and are distributed patient’s household. their insurer, employer, and/or until funds are depleted. Quali- Insurance and Co-payment creditors to resolve insurance, job fications and processes for each Information retention, and/or debt crisis matters fund may differ based on fund • Health insurance card(s) relative to their diagnosis. PAF requirements. • Details regarding assistance that seeks to safeguard patients through patient may be receiving from effective mediation assuring access Co-Pay Relief Program. Operating other co-pay or co-insurance to care, maintenance of employ- as an independent division within assistance organizations. ment, and preservation of their PAF, the Co-Pay Relief program financial stability. PAF offers offers co-pay assistance for insured NOTE: Patients should be prepared services by telephone, email, or applicants meeting disease and to share co-pay or co-insurance web chat to patients in need that income eligibility guidelines to obligations for the medications fall under the scope of our services. help patients afford the cost of relevant to the disease fund for Professional staff members offer pharmaceutical medications and which they are applying). assistance via telephone, email, or treatments. live web chat to patients in need Step 4. You will need to access to who fall under the scope of PAF’s Partnership programs. PAF works the following information for the services. Available patient services in conjunction with many nonprofit provider: from Patient Advocate Foundation and corporate partners, including • First name include: but not limited to, American • Last name Cancer Society, Susan G. Komen, • Phone number Case management. Free one-on- and Cancer Treatment Centers • Facility address one assistance with a professional of America to meet the needs of • Email address. case manager to help patients, patients across the United States. caregivers, or providers resolve Step 5. Review the application to healthcare issues. Case managers Outreach & support programs. make sure the information entered are available to assist patients, PAF performs community-based is correct and then submit the caregivers, and their providers who educational and outreach programs application online using the PAN face debilitating, chronic, or life geared towards increasing access to

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quality healthcare for underserved choose between the Patient Assi- (If there is only one program avail- populations. Contact PAF to see stance Programs database, which able for a medication, you will when they will be in your area next. searches the charitable programs be taken directly to the program offered by pharmaceutical compa- details page.) Questions? Contact Patient nies as well as RxOutreach and Advocate Foundation at: help@ Xubex, or the Generics Retail Step 5. Click the underlined patientadvocate.org or call: Programs database, which searches hyperlink of the medication you 800.532.5274. generic drug programs offered want in the search results page, and through retail pharmacies. you will be taken to the program RxAssist details page. rxassist.org To search for a medication by brand name or generic name, select Step 6. The program details page RxAssist offers a comprehen- “search by drug name.” Then, includes eligibility criteria and sive resource center for patients, enter either the complete name of information on how to apply to healthcare providers and patient the medication, or the first few the program. If an application advocates who are seeking free letters. If you type in the full name, is available for a program, you and low cost medications to the name must be spelled correctly will see “Application Forms and help manage chronic diseases. in order for the database to find Instructions” to the right with links The RxAssist database contains that medication. If you are unsure to download the application. eligibility information and appli- how to spell a drug name, type in cations for over 150 pharmaceuti- as many letters as you know to be Step 7. If an application is avail- cal company patient assistance correct. If you type the only the able online, you can either open programs. The database can help first letter, the results will include (download) the application, type you find out whether a drug is all generics and brand names that information directly onto the appli- available, which pharmaceutical begin with that letter. cation on the screen and print it company program offers the out, or print out the application drug, and how to apply for the To search a company name, select and fill it out by hand. If there is no medication. RxAssist also provides “search by company name,” then application online, use the phone practical tools, news, and articles type the company’s name into the number provided at the top of the for patients and healthcare search term box. To search the program details page to call the providers alike. RxOutreach program select the company for information on how “search by RxOutreach” button to get an application. Using RxAssist and follow the same instructions as Step 1. In order to use the those above for drug name. When NOTE: RxAssist only includes database, you must register either searching by RxOutreach, the medications that are available as a provider or patient. If you are results will only include medications through patient assistance already registered, login. Click the available through this program. programs. If your medication is not “Search Database” tab or find the listed, it most likely means that the search box in the Provider Center Step 3. If you would like to search medication is not available through or Patient Center pages. for multiple drugs, click the advance a patient assistance program. If search button. Then, enter the items you believe that the program does Step 2. Choose whether you want in the search boxes that pop up. exist, please contact RxAssist by to search by drug name or company emailing: [email protected]. If the name. Or conduct a “multiple Step 4. After you have entered medication is not available, a physi- drug” search, which allows you information in the search box, cian’s office or patient advocate to search for a drug by either the if the database finds a match a may contact the manufacturer of generic or brand name, and to search results page will appear. the medication directly to see if

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the medication could be sent their Once you have the above informa- 1. Determine patient eligibility patient. tion available, go to: www.rxhope. using criteria above. com/Prescriber/Register.aspx and 2. See if the patient’s drug is RxAssist Prescription follow the instructions. You will be listed on the RxOutreach Discount Card setting up your free account and Medication’s List: rxoutreach. Patients can save up to 80 percent creating an order for your patient org/find-your-medications. on their medications using the all at the same time. 3. Create a simple account by RxAssist Prescription Discount providing your email address Card at their local pharmacy. 21 of Rx Outreach® and selecting a password. Verify 25 most common meds are cheaper rxoutreach.org the email address provided. with the card than a $10 co-pay. 4. Enroll in Rx Outreach. To This card: Patients can use Rx Outreach enroll, you’ll need to provide • Is completely free and regardless of age or if they use the following information: never expires another discount medicine program • Name and contact infor- • Works for all FDA-approved or patient assistance program. To mation for provider and prescription medications use Rx Outreach, the patient’s patient • Supports RxAssist.org income needs to be less than a • Patient date of birth certain amount of money each year. • Patient Social Security Learn more at: rxassist.org/patients/ This amount differs depending on or Green Card number patient-assistance-center. the number of financially dependent (required to order people living in the house: Controlled Substance RxHope™ • 1-person household: Less than medications only) rxhope.com $35,010/year. (Alaska: less than • Information on patient $44,160 /year; Hawaii: less than allergies and current Healthcare providers and their staff $40,650/year.) medications can set up accounts online to order • 2-person household: Less than • Patient income and free medications for their patients $47,790/year. (Alaska: less than household size information through the RxHope automated $59,760/year; Hawaii: less than • For faster service, you can patient assistance online system. $54,990/year.) include credit card infor- If you would like to create a free • 3-person household: Less than mation for payment at account for one healthcare provider, $60,270/year. (Alaska: less than this time. visit: rxhope.com/Prescriber/Set $75,360/year; Hawaii: less than 5. Follow Rx Outreach guidelines, upAccount.aspx. To set up your $69,330/year.) seen in table below (APPENDIX free account and place orders online • 4-person household: Less than C), when writing patient’s the following criteria are required: $72,750/year. (Alaska: less than prescription. It is important • You must be a healthcare $90,960/year; Hawaii: less than that the patient’s prescription provider or their staff $83,670/year.) is written according to these • A valid state license number for • More than 4-person household: guidelines. the healthcare provider For each additional person in 6. Calculate the cost of your • An email address (this will the house, add $12,480/year. medication(s) by filling out the become your login) (Alaska: add $15,600/year; worksheet below (APPENDIX • The medication for which the Hawaii: add $14,340/year.) D) using the information patient is applying provided here: rxoutreach.org/ • The patient’s first and Providers and patients can enroll find-your-medications. last name. in the program by following the 7. Fill out and sign the Rx steps below: Outreach form. Patients will need to submit a separate

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form for each member of their household who orders medica- Tips for Assisting Patients in Applying to Patient tion. Medications can be sent Assistance Programs directly to the patient’s home, or to the provider’s office. To obtain additional forms 3 If you have any questions, call the program directly. Eligibility call 1.888.RXO.1234 requirements, drugs, dosages, even programs, change regularly so it’s (796.1234), or visit the best to go directly to the program for information. If you do not qualify Rx Outreach website. for the PAP but cannot afford your medicine, tell the representative. 8. Submit prescription and Some companies may make hardship exceptions and are willing to payment to Rx Outreach. review situations on a case-by-case basis. Sometimes you can write Payment can be made with an appeal letter to the program explaining your financial hardship. personal checks, money orders, or credit cards (only Visa, 3 MasterCard, or Discover). Review the Federal Poverty Guidelines and Percentages over the Poverty Guidelines when looking at the eligibility guidelines of a program. Send payment for the total amount along with completed Rx Outreach 3 Fill out as much information on the application as possible, including form and prescriptions. Please do the doctor’s address and phone number. Highlight the directions for not send cash. (NOTE: If patient the doctor and where he or she needs to sign. Give the doctor’s office has health insurance, they cannot an addressed-and stamped-envelope to send in the application or use their insurance to help pay highlight the fax number so it is easy to find. the Rx Outreach fee.) Prescrip- tions and payment may be faxed 3 to 1.800.875.6591. Faxed pre- Plan ahead so your medicine supply doesn’t run out. When sending in scriptions are only accepted from an application, pay attention to the refill process and the amount of a healthcare provider’s office or allowable refills. Each program is different; some require a call from the facility. Patients or providers can doctor’s office while another may allow the patient to call directly for also mail prescriptions and payment a refill; others may require a new application, which takes time. to: Rx Outreach, P.O. Box 66536, St. Louis, MO, 63166-6536. Credit 3 Be neat and complete. The directions on the application should be or debit card payment can also be completed exactly as directed. Print neatly. If something is unreadable submitted online or over the phone. or there is a blank, then the application may be denied, which can delay Once payment and prescription the process of receiving the medicine. Put “N/A” or “not applicable” in are received, please allow 24 to 48 blanks that are not filled out to indicate the material was read through hours for processing. and not skipped over. Include supplementary forms if requested. Make sure all accompanying photocopies are clean and readable. For more information, go to: rxoutreach.org or call Source. The ACCC Financial Advocacy Network. accc-cancer.org/FAN. 1.888.RXO.1234 (796.1234), Monday through Friday, 7:00 am to 5:30 pm CST.

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