ASSOCIATION OF COMMUNITY CANCER CENTERS / 2017

Patient ASSISTANCE& REIMBURSEMENT GUIDE

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

Mark S. Soberman, MD, MBA, FACS 2017-2018 President

Christian Downs, JD, MHA Executive Director

Monique J. Marino Senior Manager, Publications & Content

Amanda Patton Manager, Content

Will True 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 23,000 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 2017 Patient ASSISTANCE& REIMBURSEMENT GUIDE Financial Counselors: A Must-Have in Oncology By Gretchen Van Dyck 3 Implementing a Co-Pay Card, Foundation, and 11 Patient Assistance Billing Process By Ann Kline PAP Flow Chart 16 PAP Quick Reference Guide 18 Pharmaceutical Company Patient Assistance & Reimbursement Programs

AbbVie 26 Ipsen Biopharmaceuticals, Inc. 56 Amgen, Inc. 27 Janssen Biotech, Inc. 58 ARIAD Pharmaceuticals, Inc. 30 Lilly Oncology 61 Astellas Pharma US, Inc. 31 Merck 63 AstraZeneca 34 Novartis Pharmaceuticals Corporation 66 Bayer HealthCare Pharmaceuticals, Inc. 37 Pfizer, Inc. 69 Boehringer Ingelheim Pharmaceuticals, Inc. 39 Pharmacyclics, LLC 73 Bristol-Myers Squibb 42 Sandoz, Inc. 74 Celgene Oncology 45 Seattle Genetics 76 Eisai Co., Ltd. 47 Taiho Oncology 78 EMD Serono, Inc. 49 Takeda Oncology 79 Genentech, Inc. 51 Tesaro, Inc. 82 Incyte Corporation 54 Teva Oncology 84

Other Patient Assistance Programs & Resources

Agingcare.com® 86 The Leukemia & Lymphoma Society 90 BenefitsCheckUp® 86 NeedyMeds 90 CancerCare® 86 Partnership for Prescription Assistance 91 CancerCare® Co-Payment Assistance Foundation 87 Patient Access Network Foundation 92 Cancer Financial Assistance Coalition 88 Patient Advocate Foundation 93 Co-Pay Relief 88 RxAssist 94 Good Days 88 RxHope™ 95 HealthWell Foundation 89 Rx Outreach® 95

ACCC 2017 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 41 Lonsurf® (trifluridine and tipiracil) tablets 76 Actiq® (oral transmucosal fentanyl citrate) [C-II] 82 Lupron Depot® (leuprolide acetate for deposit suspension) 22 Adcetris® (brentuximab vedotin) for injection 74 Lynparza® (olaparib) 30 Afinitor® (everolimus) tablets 64 Mekinist® (trametinib) tablets 64 Alecensa® (alectinib) capsules 46 Neulasta® (pegfilgrastim) 23 Alimta® (pemetrexed for injection) 56 Neupogen® (filgrastim) 23 Aloxi® (palonosetron hydrochloride) 44 Nexavar® (sorafenib) tablets 33 Alunbrig (brigatinib) tablets 79 Ninlaro® (ixazomib) capsules 77 Aranesp® (darbepoetin alfa) 23 Nplate® (romiplostim) 23 Aromasin® (exemestane) tablets 67 Odomzo® (sonidegib) 64 Arzerra® (ofatumumab) injection 64 Opdivo® (nivolumab) 38 Avastin® (bevacizumab) 46 Perjeta™ (pertuzumab) 46 Bavencio® (avelumab) injection 49 Pomalyst® (pomalidomide) 41 Bendeka™ (bendamustine hydrochloride) for injection 82 Portrazza™(necitumumab) 56 Blincyto™ (blinatumomab) 23 Procrit® (epoetin alfa) 53 Bosulif® (bosutinib) tablets 67 Prolia® (denosumab) 23 Camptosar® (irinotecan hydrochloride injection) 67 Promacta® (eltrombopag) tablets 64 Cotellic™ (cobimetinib) tablets 46 Revlimid® (lenalidomide) 41 Cyramza® (ramucirumab) 56 Rituxan® (rituximab) 46 Darzalex™ (daratumumab) 53 Rydapt® (midostaurin) 66 Doxil® (doxorubicin HCl liposome injection) 53 Sandostatin® (octreotide acetate) for injection 64 Ellence® (epirubicin hydrochloride injection) 67 Sandostatin LAR® Depot (octreotide acetate 64 Emcyt® (estramustine phosphate sodium capsules) 67 for injectable suspension) Emend® (aprepitant) 59 Sensipar® (cinacalcet) 23 Emend® (fosaprepitant dimeglumine) for injection 59 Somatuline® Depot (lanreotide) for injection 51 Empliciti™ (elotuzumab) 38 Sprycel® (dasatinib) 38 Epogen® (epoetin alfa) 23 Stivarga® (regorafenib) tablets 33 Erbitux® (cetuximab) 56 Sutent® (sunitinib malate) 67 Erivedge™ (vismodegib) 46 Sylatron™ (peginterferon alfa-2b) for injection 59 Exjade® (deferasirox) tablets 64 Sylvant® (siltuximab) 53 Farydak™ (panobinostat) capsules 64 Synribo® (omacetaxine mepesuccinate) for injection 82 Faslodex® (fulfestrant) 30 Tafinlar (dabrafenib) capsules 64 Femara® (letrozole) tablets 64 Tagrisso® (osimertinib) 30 Fentora® (fentanyl buccal tablet) [C-II] 82 Tarceva® (erlotinib) 27, 46 Gardasil (Quadrivalent Human 59 Tasigna® (nilotinib) tablets 64 Papillomavirus Recombinant Vaccine) Tecentriq™ (atezolizumab injection) 46 Gardasil®9 (Human Papillomavirus 9-valent Vaccine, Recombinant) 59 Thalomid® (thalidomide) 41 Gazyva™ (obinutuzumab) 46 Temodar® (temozolomide) 59 Gilotrif™ (afatinib) 35 Torisel® (temsirolimus) for Injection 67 Gleevec® (imatinib mesylate) tablets 64 Treanda ® (bendamustine HCl) for injection 82 Granix™ (tbo-filgrastim) for injection 82 Trisenox® (arsenic trioxide) for injection 82 Halaven™ (eribulin mesylate) 44 Tykerb® (lapatinib) tablets 64 Herceptin® (trastuzumab) 46 Varubi™ (rolapitant) 80 Ibrance® (palbociclib) 67 Vectibix® (panitumumab) 23 Iclusig™ (ponatinib) 26 Velcade® (bortezomib) for injection 77 Idamycin® (idarubicin hydrochloride) for injection 67 Venclexta™ (venetoclax tablets) 46 Idhifa® (enasidenib) 45 Vidaza® (azacitidine) 41 Imbruvica® (ibrutinib) 71 Imfinzi™ (durvalumab) 34 Votrient™ (pazopanib) tablets 64 Imlygic™ (talimogene laherparepvec) 23 Xalkori® (crizotinib) capsules 67 suspension for intralesional for injection Xeloda® (capecitabine) 46 Inlyta® (axitinib) tablets 67 Xgeva™ (denosumab) 23 Intron® A (interferon alfa-2b, recombinant) for injection 59 Xofigo® (radium Ra 223 dichloride injection) 33 Iressa® (gefitinib) 30 Xtandi® (enzalutamide) capsules 27 Istodax® (romidepsin) for injection 41 Yervoy® (ipilimumab) 38 Ixempra™ (ixabepilone) 38 Yondelis® (trabectedin) 53 Jadenu™ (deferasirox) tablets 64 Zarxio™ (filgrastim-sndz) 72 Jakafi® (ruxolitinib) tablets 49 Zejula™ (niraparib) 82 Kadcyla® (ado-trastuzumab emtansine) 46 Zelboraf® (vemurafenib) 46 Keytruda® (pembrolizumab) 59 Zinecard® (dexrazoxane) for injection 67 Kyprolis® (carfilzomib) for injection 23 Zolinza® (vorinostat) 59 Lartruvo™ (olaratumab) 56 Zykadia™ (ceritinib) capsules 64 Lenvima™ (lenvatinib) capsules 44 Zytiga® (abiraterone acetate) 53

2 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org TABLE OF CONTENTS

Financial Counselors: A Must Have in Oncology

By Gretchen Van Dyck

As an innovator in the oncology field, Green Bay Oncology Hospital Sisters Health System St. Vincent Hospital, has created a solid financial counseling program to ensure becoming part of the regional cancer center and making that no patients have to carry the financial burden that us the largest oncology group in northeast Wisconsin. may accompany a cancer diagnosis by themselves. By sharing our story, the financial counseling team hopes Today, we have a team of 6 counselors assisting 9 med- other cancer programs can benefit from our experiences ical oncologists, 3 pediatric oncologists, 3 radiation to either develop their own financial counseling services oncologists, 1 gynecology oncologist, 8 nurse practitio- or to enhance existing services. ners, and 3 physician assistants across 6 cancer center locations in northeast Wisconsin and the Upper Peninsula Our Story of Michigan. The financial counseling position at Green Bay Oncology began as a 1 person team 10 years ago when our group In our comprehensive cancer program, financial coun- consisted of 7 physicians and 6 clinic locations. At a time selors follow patients from the start to the completion when prior authorizations for IV chemotherapy were still of their treatment journey and are an integral part of unheard of, the financial counselor’s basic responsibili- the patient’s experience. We act as a liaison between the ties consisted of meeting with uninsured patients who patient, the provider, and other clinic departments, as needed to start treatment and working with the pharma- well as the patient’s insurance carrier. Efficient commu- ceutical companies to get free drug, if available. Over the nication between all of these individuals and depart- next few years, however, the financial counselor position ments is the core of our program’s success. We are also continued to grow along with patient demand and began fortunate to have providers who understand the key to include assistance for oral anti-cancer agents as well. message concerning financial toxicity and its poten- tial to impact patient outcomes. “Medicine in general, Given the growing complexity of cancer care, along with and oncology in particular, used to believe that money the increase in the number and cost of oral anticancer shouldn’t be a consideration in treatment,” said Green therapies, it is no surprise that the financial counselor Bay Oncology provider Mitch Winkler, MD. “This led us to program quickly became an important part of Green act as if ‘money was no object’ where cancer treatment Bay Oncology. In 2015, Green Bay Oncology aligned with was concerned. We feared that considering financial

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 3 TABLE OF CONTENTS

factors would harm our patients or impede their care. But After meeting with the patient, we fax the prescription by neglecting financial factors in cancer treatment, we’ve along with the patient’s demographics, current medi- exposed our patients to terrible harm.” cation list, and copies of insurance cards to our single point of contact at the specialty pharmacy. Because Our Process we have a pre-existing relationship with this point of The financial counselor’s job begins before the patient steps contact, communication is often quick and easy, helping foot in our clinic. Acting as an advocate for patients, our to ensure that the medication gets to the patient in a benefits specialist will first verify their insurance ben- timely manner. efits to ensure patients are in-network with our physicians. Our pharmacy contact will notify us if an authorization Once treatment is prescribed, whether IV, oral, or radia- is required. Once we receive that notification we then tion therapy, the financial counselor will immediately submit to the insurance company for the approval. When verify that the treatment is indicated for the patient’s approval has been obtained, we notify the pharmacy and diagnosis, checking the National Comprehensive the financial counselor is then given a date when the Cancer Network (NCCN) Compendium and/or the patient is scheduled to receive his or her medication. Medicare Compendium. We then verify that the patient has an appointment scheduled for a toxicity evaluation within 10 days Next, we verify whether the patient’s insurance requires from the date the medication is received. prior authorization. If so, we initiate the authoriza- tion process immediately to ensure that treatment can Financial Assistance for IV & Oral start within three to five days. Once we’ve obtained the Therapy authorization approval, we continue to follow the patient If the physician is ordering a treatment that is not yet to ensure that if treatment continues longer than antici- FDA approved for the patient’s diagnosis, or not indicated pated, the approval does not lapse. We are able to generate (i.e., off-label), we will always try to get approval through a notification in our electronic health record (EHR) that the insurance company first. If we receive a denial from will alert us of an expiring authorization two weeks before the insurance company, we then go straight to the phar- the expiration date. We can then go into the patient’s chart maceutical company and apply to the patient assistance and determine if reauthorization is needed. program in hopes to receive free drug assistance for our patients. We do not ask patients to fill out any patient For patients treated with oral therapies, our financial assistance forms; all forms are completed and sent in by counselors initiate the first prescription fill with the financial counselor. All that is needed from patients specialty pharmacy to verify insurance approval and is their signature and, if required, income documentation make sure the medication is affordable for the patient. to ensure eligibility. The financial counselors first meet with patients while they are in the clinic, explain how specialty/mail-order When patients are first diagnosed and prescribed treat- pharmacies operate and—depending on their ment, one of their first concerns is usually “How am I insurance—discuss co-pay assistance. going to afford this?” Most will have insurance to assist

continued on page 6

4 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org TABLE OF CONTENTS

Commercial policy

Understanding Your Health Insurance Benefits

Date Prepared:______Patient Name:______Date of Birth:______Insurance Carrier: ______Policy Number:______In Network? Yes No Primary Policy? Yes No

Health care expenses can vary from patient to patient. The following is prepared to assist you in understanding your health care terms and benefits.

$______Co-Pay: A fixed amount you pay for a healthcare service, paid when you receive the service, i.e. office visits. As this is a specialist office, this amount may be higher than what you normally pay for your primary care physician visits. Co-pays are due at the time of service.

$______Annual Deductible: A specified amount of money that the insured (you) must pay before an insurance company will pay a claim.

Deductible met: $______

Deductible remaining: $______

______% Co-Insurance: Your share of the costs of a healthcare service. This is usually figured as a percentage of the amount your insurance carrier allows to be charged for services. You start paying coinsurance after you’ve paid your plan’s deductible.

$______Out-of-Pocket Maximum: The most you will have to pay for covered healthcare services in a plan year through deductible and coinsurance before your insurance plan begins to pay 100% of covered healthcare services. Co-Pays and deductibles may or may not apply to this amount, this varies by insurance plan.

Out-of-Pocket Maximum met: $______

Out-of-Pocket Maximum remaining: $______

Do co-pays apply to my out-of-pocket maximum? YES NO

Notes:______

Financial Counselors are available to assist you with any insurance or financial related questions during the course of your treatment. Please feel free to stop in or call 920-884-3135 (toll free 866-884- 3135) to speak with a Financial Counselor.

This is not a guarantee of benefits; we have made every effort to obtain correct benefit information from your insurance carrier. Final determination of your benefits will be dictated by your insurance company at the time claims are processed. Therefore, your patient responsibility may be different.

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 5 TABLE OF CONTENTS

continued from page 4

them with their treatments and appointments but, as With the constant increase of insurance plans’ yearly we all know, the out-of-pocket maximums on insurance out-of-pocket maximums, the amount of money our plans just keep getting larger. It is important to meet program saves our patients each year continues to grow. with patients before they start treatment and discuss Figure 1, page 7, illustrates exactly what was paid to our cost and options to help alleviate any financial burdens clinic from foundations and pharmaceutical co-pay cards. of cancer treatment. This does not reflect the full grant amount that was issued to patients. In 2015, between IV and oral chemo- Depending on the type of treatment, we will go over therapy assistance, the financial counselors at Green Bay options, such as foundation assistance on the national Oncology saved patients more than 1 million dollars! level (Patient Advocate Foundation, Patient Access Network Foundation, CancerCare, etc.) or on the local level. Financial Assistance for Radiation For example, in northeast Wisconsin we have some great Oncology local foundations, such as Ribbon of Hope and the Ovarian Unfortunately the radiation oncology world is a little Cancer Community Outreach (OCCO), to help reduce not bit different in terms of financial assistance. There is only treatment costs, but everyday living costs as well. very limited access to patient assistance for radiation oncology patients when it comes to treatment; for that Once approved, we will add these foundations to reason we like to meet with these patients before they the patient’s EHR and take care of all submissions for start radiation therapy. payment. Claims are sent to the foundation before patients receive a bill. This process is in place to alleviate Our financial counselors provide patients with an as much of the financial burden as we can from patients overview of their insurance coverage, including their in hopes of reducing any anxiety caused by additional out-of-pocket responsibility, what they’ve met, and bills and/or collection phone calls. how much they have remaining. Also, specific forms (see page 5) are given to each patient, depending on their For commercially-insured patients who do not qualify type of coverage, i.e., commercial, Medicare Advantage, or for foundation assistance and/or for whom there are no Medicare and a supplement. This information helps give funds available for their diagnosis, we will turn to phar- patients an idea of how much they may be responsible for. maceutical company co-pay cards. These drug-specific cards can be a great option for reducing out-of-pocket We also talk to these patients upfront regarding payment costs. There is no income limitation for these cards so plans, as well as Community Care/Charity Care if they long as patients give us their consent to enroll them; feel this is something they would be eligible for. Patients financial counselors can take care of everything, are also made aware that a financial counselor will including submitting charges on their behalf. be given their treatment plan in order to verify that everything is indicated and authorized prior to their In 2015 alone, we saved our patients $573,328.50 on their beginning therapy. oral chemotherapy co-pays. This amount is only from three of the main specialty pharmacies we use: Accredo, Due to the success of these forms in our radiation Diplomat, and Community Pharmacies. Recently, in 2016, oncology department, our goal is to meet with and the financial counseling team worked closely with the provide these same benefits to all patients in the hospital’s charity foundation and reached out to donors medical oncology clinic by 2017. to create a specific fund for our patients on oral therapy that could be used when all other foundation funds At Green Bay Oncology, our financial counselors do not were exhausted. just handle the above-mentioned duties. Financial coun-

6 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org TABLE OF CONTENTS Assistance for IV Therapy

$450,000.00 $436,483.68 $400,000.00

$ 350,000.00 $340,604.81 $300,000.00 $281,512.31 $ 250,000.00

$200,000.00 $167,807.35 $168,863.36 $ 150,000.00

$ 100,000.00

$ 50,000.00 2011 2012 2013 2014 2015

selors are constantly involved in projects, creating new Financial counselors work closely with physicians to processes and building teams within other departments develop and continually update clinical pathways. to continue driving our cancer program forward. These disease-specific pathways help standardize our approach to how we treat our patients while showing Financial counselors work closely with social workers payers that we are consistent in our treatment plans. and nurse navigators to make sure patients are taken Counselors verify that all treatments are listed in the care of both inside and outside of the clinic, including NCCN Compendium while taking into consideration the ensuring patients have all the necessary appointments cost of the therapy—not only for the patient, but also for scheduled, transportation to and from the clinic, or the clinic. assistance to help with everyday bills that seem to take a backseat when medical bills start accumulating. The financial counselors are the patient’s direct point of contact for any and all billing concerns. Patients are Our team also works with outside resources to enroll instructed to call their financial counselor with any eligible patients in Medicaid. Financial counselors questions or concerns they may have once they start can also refer underinsured patients to the proper receiving bills. We work with patients to set up payment resources to gain the additional coverage they need plans tailored to their comfort level. going forward, such as Medicare supplemental plans and/or prescription coverage (Medicare Part D). The Community Care applications are also given to patients open communication between departments is a prime once all other assistance options have been exhausted. example of how our cancer program strives to always Some factors taken into consideration while processing put patients first. Community Care applications include annual household

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 7 TABLE OF CONTENTS

income, household size, assets and debt information, Institutions that do not think they need financial coun- and the past three months of bank statements. Once the selors should answer these questions: signed application and all required financial documenta- • What does your Patient A/R (Accounts Receivable) tion are returned, financial counselors process these and stand at? inform patients of the amount of assistance for which • How are your patients affording their treatments? they have been approved. • How much are you writing off as charity? • How many patients are you sending to collections? On top of all medication authorizations, including chemotherapy and retail prescriptions, our team also Financial counseling is not only a service to assist the authorizes any radiology imaging that is ordered by patients; it also guarantees the clinic is going to get paid. providers, as well as molecular lab testing such as chro- It’s 2017 and the cost of care is going to continue to climb. mosome analysis, BCR/ABL, and JAK2 orders. It’s very Committing as a practice or program to be financially important to verify coverage for any testing ordered by responsible to patients has to be at the forefront. physicians to prevent that financial burden from falling into our patients’ laps. By attending multiple ACCC meetings (the Financial Advocacy Network [FAN] Meetings, Oncology Reim- When our clinic does receive a denial from a payer on bursement Meetings [ORMs], and the National Oncology any physician-ordered treatment, it is our financial Conference) our financial counselors have experienced counseling team’s responsibility to appeal. We will draft ample opportunity for networking with other clinics a letter to send to the payer along with all supporting across the country who have continually expressed their documentation, such as compendium listings, FDA indi- desire to learn more about our comprehensive finan- cations, insurance policies, etc. Our team is proud to say cial counseling program. We have provided consulting it’s not very often that the denials are upheld once our services to several other cancer programs in Wisconsin appeals are submitted. and Michigan, helping them replicate our financial coun- selor position within their own program. ACCC meetings Working for a hospital system that understands the need have opened our eyes to the fact that there are far too for financial counselors is imperative. We hear far too many cancer programs that are unaware of how they often while attending conferences around the region that can help mitigate financial toxicity for their patients. It cancer programs are trying to “prove” to their leadership is vital for us to educate the cancer community on the that a financial counselor position is feasible. We think to importance of financial toxicity prevention. Won’t you ourselves, “What? You have to prove it?” Don’t the numbers join us? y speak for themselves? Gretchen Van Dyck is a financial counselor, St. Vincent Regional Cancer Center, Green Bay, Wisc.

8 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org B:8.75” T:7.875” S:6.875”

TABLE OF CONTENTS

The Eisai Co-Pay Programs Expanding patient access to HALAVEN® and LENVIMA®

Eisai Inc., the maker of HALAVEN and LENVIMA, offers $0 Co-Pay Programs to assist eligible, commercially insured B:11.5” T:10.5”

patients with the out-of-pocket costs for their prescriptions.* S:9.5”

The $0 Co-pay Programs are offered through the Eisai Assistance Program, which is designed to help facilitate access and reimbursement support for health care providers and patients. Additional benefits include reimbursement information, insurance verification, alternate coverage advising, and financial assistance programs. Eisai cannot guarantee coverage or eligibility for any benefits or programs.

To learn more about the $0 Co-Pay Programs and the Eisai Assistance Program

• Call 1-866-61-EISAI (1-866-613-4724), 8 AM to 8 PM ET, Monday through Friday • Visit www.EisaiReimbursement.com

*Maximum benefit: The HALAVEN and LENVIMA $0 Co-Pay Programs each provide eligible patients up to $18,000 and $40,000 per year, respectively, to assist with the out-of-pocket costs for prescriptions. Depending on the insurance plan, your patient could have additional financial responsibility for any amounts over Eisai’s maximum liability. Other terms and conditions apply.

HALAVEN® and LENVIMA® are registered trademarks used by Eisai Inc. under license from Eisai R&D Management Co., Ltd. © 2016 Eisai Inc. All rights reserved. Printed in USA/July 2016 CORP-US0160

EISC-64509_M4_OncRmbrsmnt_JA_Asze.indd Printed At None Saved at 7-6-2016 10:59 AM from hsdlondono7606 by Deja Londono / Judy Law

Job info Images Fonts & Colors Client Code CORP-US0160 EISAI_Gradient_Boxes_Blue.ai (62.94%, 49.43%), 64509_Eisai-Co- Colors Client EISAI Corporate Pay_LockUp.ai (29.25%), Halaven_Logo_4C.ai (42.24%), Lenvima_ Cyan, Magenta, Yellow, Black Logo_wDose_noTag_R_4C.ai (43.74%), Eisai_Logo.eps (4.32%), Live 6.875” x 9.5” EAP_LOGO_4C.ai (54.78%) Fonts Overall Trim 7.875” x 10.5” Gotham (Book), Helvetica Neue LT Std (65 Medi- Bleed 8.75” x 11.5” um, 75 Bold, 35 Thin)

# of Colors 4/0

Notes None TABLE OF CONTENTS

Implementing a Co-Pay Card, FOUNDATION, and Patient Assistance Billing Process

THE MERCK ACCESS PROGRAM

May Help Answer Questions About • Benefi t investigations for your patients • Information about prior authorizations and appeals • Billing and coding • Referrals to the Merck Patient Assistance Program • Product distribution • Co-pay assistance for eligible patients

Contact The Merck Access Program (MAP) Visit merckaccessprogram-keytruda.com. Call 855-257-3932 Monday through Friday, 8 AM to 8 PM ET. Register for the secure Merck Access Portal to Complete the MAP enrollment form online and submit it electronically. The Portal provides for the use of electronic signatures

Track benefi t investigation and enrollment requests to help you monitor where your patients are in the enrollment or benefi t investigation process

Receive notifi cations and update practice information from a central dashboard

To register your practice for the Merck Access Portal, visit merckaccessprogram-keytruda.com.

Copyright © 2016 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. All rights reserved. ONCO-1175800-0000 04/16 keytruda.com TABLE OF CONTENTS

Implementing a Co-Pay Card, FOUNDATION, and Patient Assistance Billing Process

By Ann Kline

s an oncology service line within a clinics. Key to the success of our financial advocacy healthcare system, St. Luke’s Mountain program is our ability to leverage co-pay, foundation, States Tumor Institute (MSTI), Boise, and patient assistance programs for our patients Idaho, is the only service line that has through our consistent authorization process, suc- a dedicated financial advocacy program cessful management of our self-pay population, and Astaffed with 19 FTES. The Advocates are budgeted under documented data on all levels of assistance provided the Administrative Support of each of the five MSTI to our patients.

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 11 TABLE OF CONTENTS

Step 1. Engage Key Stakeholders then apply for available assistance based on disease and When setting up a process for accessing co-pay, founda- treatment type. If your financial advocates do not handle tion, and patient assistance funds, transparency and authorizations, the authorizations team can set up a good communication are essential. The first step in process to notify Financial Advocacy to apply for patient setting up the billing process for these financial advocacy assistance when needs are identified. services is to engage key stakeholders, including: • Payments and Cash Posting Management Step 2. Develop a Process for • Billing Insurance Billing & Follow-Up • Customer Service When we first designed our financial advocacy program, • Financial Advocacy team members. the billing coordinator role was initially envisioned as a clerical one, but it quickly became clear that we These stakeholders have a vital role in ensuring needed more from this position. We hired someone from the long-term viability of the billing process. For our Insurance Follow Up Team within our healthcare example, Payments and Cash Posting Management system’s billing department who already knew how to must establish a process for identifying and tracking access the correct forms needed to bill the programs and payments from co-pay, foundation and patient assis- how to identify when claims needed to be billed, rebilled, tance programs, which can come in a variety of forms, or corrected. This individual also had working relation- including credit card authorization numbers and checks ships established in all areas of the billing department, from third-party payers that look like they are coming making her job easier. In addition to billing co-pay from an insurance company. cards, foundations, and patient assistance programs, the coordinator also bills patients’ cancer policies and Billing needs to submit patient claims in a timely fashion provides billing support to our Financial Advocacy team. to avoid bottlenecks and so co-pay, foundation, and The savings realized from our billing process continues to patient assistance programs can be billed in a timely exceed the cost of hiring this vital staff person. manner. To bill a co-pay, foundation, and/or patient assistance Customer Service may receive calls from patients trying program, the billing coordinator faxes the Explanation to pay with their Co-Pay Card or from patients who are of Benefits (EOB), showing the program-designated upset at being balanced-billed when they have a Co-Pay charge (for example, the supported drug) that was Card or Foundation Assistance, and must be prepared to charged by the provider and then processed by the payer respond or refer these patients to the appropriate staff and the subsequent patient responsibility resulting member. A designated billing coordinator assigned to from that charge after claim processing. This process is track patients and their co-pay, foundation, and patient more efficient than waiting for patients to bring in their assistance funds can help to alleviate confusion. EOBs. In some situations, the billing coordinator is able to upload these documents if the program portal has Financial Advocacy needs to screen all patients to not that capability. only ensure claims are getting paid but to help limit and/ or decrease patient financial liability. Financial advocates The response time for payment by the co-pay, must be aware of patients’ prescribed treatments, and foundation, and/or patient assistance program

12 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org TABLE OF CONTENTS

varies. Sometimes you receive an instant fax response or, barriers. One avenue that I have yet to explore is talking in some cases, an email confirmation, while other times with various EHR vendors since they create the billing the billing coordinator must make multiple follow-up modules that we all work with. queries to ensure payment. To expedite claims processes, clarify that patients have not met their out-of-pocket Our healthcare system has not yet instituted automated responsibilities and that the co-pay, foundation, and/or billing; however, automated reports would be a huge win patient assistance program award amount has not yet for the Financial Advocacy program. Currently we manu- been exceeded prior to sending claims. While these steps ally track data in Excel spreadsheets to show administra- may seem obvious, they can cause delays in payment. tion the dollar amount brought in as a service line to help drive down patient collections, charity write-offs, and Step 3. Identify Future Needs & bad debt. Those Excel reports are good, but automated Process Improvements reports would certainly contain less human error and MSTI started its financial advocacy program three years could be generated faster. ago in January 2014, and we are still working to simplify our billing and payment recovery processes. Our health Neglecting to implement a streamlined process to bill system uses EPIC as its electronic health record (EHR), these co-pay, foundation, and/or patient assistance and we have not yet found a way to bill co-pay, founda- programs is like saying you don’t want to get paid. Assis- tion, and/or patient assistance programs electronically tance funds are available and—with a bit of work—can or to set up a secondary payer plan to print out paper be relatively easy to access for your patients. Our inno- claims. This limitation creates work queues with patient vative financial advocacy process has increased patient responsibility claims that are waiting for programs to satisfaction, freed up financial advocate staff to perform pay, which can drive up our Accounts Receivable days. other duties, helped patients pay down out-of-pocket costs, and reduced our charity and bad debt write-offs. Payment identification is another area that needs improvement. Any payments other than insurance Ann Kline is the former manager of Revenue & Reim- payments are listed as “patient payments,” even though bursement at St. Luke’s Mountain States Tumor Institute, these payments may be co-pay, foundation, and/or Boise, Idaho. Ann has returned to being a Patient Advo- patient assistance payments. This lack of clarity causes cate and continues to help other facilities learn how to additional work for the billing coordinator to deter- have a successful Advocacy program through ACCC and mine if payments have been received. Communication Genentech Speaker Bureau. y is critical between the billing coordinator and Payment and Cash Posting Management. Currently, when Cash Management does not recognize a payment or identi- fies that payment as one of the programs that our billing Learn more about MSTI’s Financial Advocacy services coordinator follows up on, a notification is sent out to the by reading Ann Kline’s article, billing coordinator to follow up on these payments. “Accessing Co-Pay Assistance Opportunities” online at accc-cancer.org/publications/pdf/Kaley-Article-PAGuide-2016.pdf. We continue to talk with pharmaceutical representatives and foundation groups about how we can remove these

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 13 TABLE OF CONTENTS

ACCC INTRODUCES FINANCIAL ADVOCACY BOOT CAMP

Powerful Training to Take Your Financial Advocacy Skills to the Next Level

hether you’re an experienced fi nancial advocate or new Wto the fi eld, there’s no better time to shape up your skills. FINANCIAL ADVOCACY BOOT CAMP offers a dynamic online curriculum for you to help cancer patients navigate the complex and fragmented healthcare system.

Brought to you by the Association of Community Cancer Centers (ACCC) and its Financial Advocacy Network (FAN), this FREE online program provides the key knowledge and skills to excel in the increasingly essential arena of fi nancial advocacy:

• Financial Advocacy Fundamentals • Enhancing Communication • Improving Insurance Coverage • Maximizing External Assistance • Developing & Improving Financial Advocacy Programs & Services Who Should Enroll? Financial advocates, nurses, patient navigators, social workers, pharmacists, pharmacy techs, medical coders, administrative staff, cancer program administrators, and other healthcare providers. Enroll today: accc-cancer.org/FANBootCamp

The Financial Advocacy Network (FAN) provides needed resources and expands the skills and knowledge base of providers who deal directly with patients on complex fi nancial 14 ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org issues/ surrounding their cancer diagnosis and treatment. TABLE OF CONTENTS

ACCC INTRODUCES THANK YOU / to our supporters

FINANCIAL ADVOCACY INDUSTRY ADVISORY COUNCIL BOOT CAMP

Powerful Training to Take Your Financial Advocacy Skills to the Next Level hether you’re an experienced fi nancial advocate or new Wto the fi eld, there’s no better time to shape up your skills. FINANCIAL ADVOCACY BOOT CAMP offers a dynamic online curriculum for you to help cancer patients navigate the complex and fragmented healthcare system. EMERGING COMPANIES COUNCIL Brought to you by the Association of Community Cancer Centers (ACCC) and its Financial Advocacy Network (FAN), this FREE online program provides the key knowledge and skills to excel in the increasingly essential arena of fi nancial advocacy:

• Financial Advocacy Fundamentals • Enhancing Communication • Improving Insurance Coverage • Maximizing External Assistance • Developing & Improving Financial Advocacy Programs & Services Who Should Enroll? Financial advocates, nurses, patient navigators, social workers, pharmacists, pharmacy techs, medical coders, administrative staff, cancer program administrators, and other healthcare providers. Enroll today: TECHNICAL ADVISORY COUNCIL accc-cancer.org/FANBootCamp

The Financial Advocacy Network (FAN) provides needed resources and expands the skills and knowledge base of providers who deal directly with patients on complex fi nancial ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org 15 issues surrounding their cancer diagnosis and treatment. / TABLE OF CONTENTS

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 2017 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 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 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.

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.

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 17 TABLE OF CONTENTS

PAP /quick reference guide

BENEFIT VERIFICATION AND DRUG COMPANY FOUNDATION AUTHORIZATION CO-PAY AND OTHER 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 X P X 1.877.814.3915 www.gilotrifhcp.com/solutions-plus/access-reimbursement 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 https://www.proleukin.com/ 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 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.astrazenecaspecialtysavings.com 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 Atezolizumab Tecentriq Genentech X X X X 1.866.422.2377 www.genentech-access.com/hcp.html ATRA Vesanoid Roche X www.roche.com/index.htm Avelumab Bavencio EMD Serono 1.844.826.8371 www.coverone.com Axitinib Inlyta Pfizer X X D,P,H,F,A,X X 1.877.744.5675 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/medicines/Affordability.html 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.amgenassist360.com/hcp/ Bortezomib Velcade Millennium X D,H,P X 1.866.835.2233 www.velcade.com/payingfortreatment.aspx Bosutinib Bosulif Pfizer X X D,P, H,A,X X 1.877.744.5675 www.pfizerrxpathways.com Brentuximab vedotin Adcetris Seattle Genetics X X P X 1.855.473.2436 www.seagensecure.com Brigatinib Alunbrig Takeda X X X 1.844.817.6468 www.ariadpass.com/hcp_alunbrig.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 Cabometyx Exelixis X X D, P, H, F 1.844.900.3273 www.ease.us 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.amgenassist360.com/hcp/ 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 Eli Lilly X X D,H,P X 1.866.472.8663 www.lillypatientone.com Chlorambucil Leukeran X P X 1.844.900.3273 https://hcp.cabometyx.com/access-support/ 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 CPT-11 Camptosar Pfizer X D,H,P X 1.877.744.5675 www.pfizerrxpathways.com Crizotinib Xalkori Pfizer X X H,F,P,A X 1.877.744.5675 www.pfizerrxpathways.com Cyclophosphamide Cytoxan H 1.800.675.8416 www.healthwellfoundation.org Cyclophosphamide Neosar H 1.800.675.8416 www.healthwellfoundation.org

18 / ACCC 2017 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 = https://diplomat.is/patients 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 X P X 1.877.814.3915 www.gilotrifhcp.com/solutions-plus/access-reimbursement 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 https://www.proleukin.com/ 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 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.astrazenecaspecialtysavings.com 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 Atezolizumab Tecentriq Genentech X X X X 1.866.422.2377 www.genentech-access.com/hcp.html ATRA Vesanoid Roche X www.roche.com/index.htm Avelumab Bavencio EMD Serono 1.844.826.8371 www.coverone.com Axitinib Inlyta Pfizer X X D,P,H,F,A,X X 1.877.744.5675 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/medicines/Affordability.html 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.amgenassist360.com/hcp/ Bortezomib Velcade Millennium X D,H,P X 1.866.835.2233 www.velcade.com/payingfortreatment.aspx Bosutinib Bosulif Pfizer X X D,P, H,A,X X 1.877.744.5675 www.pfizerrxpathways.com Brentuximab vedotin Adcetris Seattle Genetics X X P X 1.855.473.2436 www.seagensecure.com Brigatinib Alunbrig Takeda X X X 1.844.817.6468 www.ariadpass.com/hcp_alunbrig.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 Cabometyx Exelixis X X D, P, H, F 1.844.900.3273 www.ease.us 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.amgenassist360.com/hcp/ 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 Eli Lilly X X D,H,P X 1.866.472.8663 www.lillypatientone.com Chlorambucil Leukeran X P X 1.844.900.3273 https://hcp.cabometyx.com/access-support/ 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 CPT-11 Camptosar Pfizer X D,H,P X 1.877.744.5675 www.pfizerrxpathways.com Crizotinib Xalkori Pfizer X X H,F,P,A X 1.877.744.5675 www.pfizerrxpathways.com Cyclophosphamide Cytoxan H 1.800.675.8416 www.healthwellfoundation.org Cyclophosphamide Neosar H 1.800.675.8416 www.healthwellfoundation.org

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 19 TABLE OF CONTENTS

PAP /quick reference guide

BENEFIT VERIFICATION AND DRUG COMPANY FOUNDATION AUTHORIZATION CO-PAY AND OTHER DRUG NAME BRAND NAME DRUG COMPANY SUPPORT ASSISTANCE ASSISTANCE 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 www.patientassistancenow.com Defibrotide sodium Defitelio Jazz Pharmaceuticals 1.888.837.4397 https://www.jazzpharma.com/responsibility/patient-assistance/ 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 1.877.744.5675 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 Durvalumab Imfinzi AstraZeneca X 1.800.292.6363 www.astrazeneca-us.com/medicines/Affordability.html 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 Enasidenib Idhifa Celgene Enzalutamide Xtandi Astellas X X D,P X 1.855.898.2634 astellaspharmasupportsolutions.com Epirubicin Ellence Pfizer X D,H X 1.877.744.5675 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 http://www.eisaireimbursement.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 1.877.744.5675 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,A X 1.877.744.5675 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/medicines/Affordability.html Gefitinib Iressa AstraZeneca H, P X 1.800.292.6363 www.astrazeneca-us.com/medicines/Affordability.html Granisetron Transdermal Sancuso Prostrakan 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/patient-support/access-support Idarubicin Idamycin Pfizer X X 1.877.744.5675 www.pfizerrxpathways.com 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 https://www.proleukin.com/

20 / ACCC 2017 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 = diplomat.is/patients/ 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 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 www.patientassistancenow.com Defibrotide sodium Defitelio Jazz Pharmaceuticals 1.888.837.4397 https://www.jazzpharma.com/responsibility/patient-assistance/ 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 1.877.744.5675 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 Durvalumab Imfinzi AstraZeneca X 1.800.292.6363 www.astrazeneca-us.com/medicines/Affordability.html 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 Enasidenib Idhifa Celgene Enzalutamide Xtandi Astellas X X D,P X 1.855.898.2634 astellaspharmasupportsolutions.com Epirubicin Ellence Pfizer X D,H X 1.877.744.5675 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 http://www.eisaireimbursement.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 1.877.744.5675 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,A X 1.877.744.5675 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/medicines/Affordability.html Gefitinib Iressa AstraZeneca H, P X 1.800.292.6363 www.astrazeneca-us.com/medicines/Affordability.html Granisetron Transdermal Sancuso Prostrakan 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/patient-support/access-support Idarubicin Idamycin Pfizer X X 1.877.744.5675 www.pfizerrxpathways.com 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 https://www.proleukin.com/

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 21 TABLE OF CONTENTS

PAP /quick reference guide

BENEFIT VERIFICATION AND DRUG COMPANY FOUNDATION AUTHORIZATION CO-PAY AND OTHER DRUG NAME BRAND NAME DRUG COMPANY SUPPORT ASSISTANCE ASSISTANCE 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 1.877.744.5675 www.pfizerrxpathways.com Irinotecan Liposome Onivyde Merrimack Pharmaceuticals 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/financial-resources 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 Levoleucovorin Fusilev Teva 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 Methotrexate Xatmep Silvergate Midostaurin Rydapt Novartis X X X 1.800.282.7630 www.us.rydapt.com/interested-in/patient-support/ Mitomycin Mutamycin D,H,P Mitoxantrone Novantrone D,H,P Morphine sulfate Arymo Egalet 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 Neratinib Nerlynx Puma Biotechnology 1.855.816.5421 www.nerlynx.com/support Netupitant/Palonosetron Akynzeo X X 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 Niraparib Zejula Tesaro, Inc. X X X 1.844.283.7276 www.togetherwithtesaro.com Nivolumab Opdivo Bristol-Myers Squibb X X X 1.800.861.0048 www.bmsaccesssupport.bmscustomerconnect.com/oncology/ services/patient-financial-assistance Obinutuzumab Gazyva 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/Affordability.html Olaratumab Lartruvo Eli Lilly X X X 1.866.472.8663 www.lillypatientone.com Omacetaxine Mepesuccinate Synribo Teva Pharmaceuticals X D,P X X 1.888.587.3263 www.cephalononcologycore.com Osimertinib Tagrisso AstraZeneca X X X 1.844.275.2360 www.myaccess360.com/access-360-for-healthcare-professionals -and-patients.html 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 H,F,P,A X 1.877.744.5675 pfizerrxpathways.com/ Palonosetron Aloxi Eisai X X 1.866.613.4724 http://www.eisaireimbursement.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 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

22 / ACCC 2017 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 = diplomat.is/patients/ 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 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 1.877.744.5675 www.pfizerrxpathways.com Irinotecan Liposome Onivyde Merrimack Pharmaceuticals 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/financial-resources 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 Levoleucovorin Fusilev Teva 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 Methotrexate Xatmep Silvergate Midostaurin Rydapt Novartis X X X 1.800.282.7630 www.us.rydapt.com/interested-in/patient-support/ Mitomycin Mutamycin D,H,P Mitoxantrone Novantrone D,H,P Morphine sulfate Arymo Egalet 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 Neratinib Nerlynx Puma Biotechnology 1.855.816.5421 www.nerlynx.com/support Netupitant/Palonosetron Akynzeo X X 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 Niraparib Zejula Tesaro, Inc. X X X 1.844.283.7276 www.togetherwithtesaro.com Nivolumab Opdivo Bristol-Myers Squibb X X X 1.800.861.0048 www.bmsaccesssupport.bmscustomerconnect.com/oncology/ services/patient-financial-assistance Obinutuzumab Gazyva 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/Affordability.html Olaratumab Lartruvo Eli Lilly X X X 1.866.472.8663 www.lillypatientone.com Omacetaxine Mepesuccinate Synribo Teva Pharmaceuticals X D,P X X 1.888.587.3263 www.cephalononcologycore.com Osimertinib Tagrisso AstraZeneca X X X 1.844.275.2360 www.myaccess360.com/access-360-for-healthcare-professionals -and-patients.html 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 H,F,P,A X 1.877.744.5675 pfizerrxpathways.com/ Palonosetron Aloxi Eisai X X 1.866.613.4724 http://www.eisaireimbursement.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 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

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 23 TABLE OF CONTENTS

PAP /quick reference guide

BENEFIT VERIFICATION AND DRUG COMPANY FOUNDATION AUTHORIZATION CO-PAY AND OTHER DRUG NAME BRAND NAME DRUG COMPANY SUPPORT ASSISTANCE ASSISTANCE Pembrolizumab Keytruda Merck X X D,H X 1.855.257.3932 www.merckaccessprogram-keytruda.com Pemetrexed Alimta Eli Lilly X X 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 Ribociclib Kisqali Novartis 1.800.282.7630 https://www.hcp.novartis.com/access Rituximab Rituxan Genentech X X D,H,P X 1.866.422.2377 www.genentech-access.com/hcp Rolapitant Varubi Tesaro, Inc. X X X 1.844.283.7276 https://www.togetherwithtesaro.com/ 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 Rucaparib Rubraca Clovis Oncology X X X 1.844.779.7707 http://rubracaconnections.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 http://www.provenge.com/reimbursement 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 X D,P,H,F,A,X X 1.877.744.5675 www.pfizerrxpathways.com Talimogene laherparepvec Imlygic Amgen X X X 1.888.427.7478 AmgenAssistOnline.com Tamoxifen Nolvadex H,M TBO-Filgrastim Granix Teva Oncology X X 1.888.587.3263 http://tevacore.com Telotristat Ethyl Xermelo Lexicon Pharmaceuticals Temozolomide Temodar Merck D 1.800.727.5400 www.merckhelps.com Temsirolimus Torisel Pfizer X P,H,F,A X 1.877.744.5675 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 Genzyme X X P X 1.800.367.4999 www.caprelsa.com/pt_resources_and_support.asp Valrubicin Valstar Endo Pharmaceuticals X Vemurafenib Zelboraf Genentech X X P X 1.866.422.2377 www.genentech-access.com/hcp Venetoclax Venclexta Genentech X X 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 2017 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 = diplomat.is/patients/ 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 Pembrolizumab Keytruda Merck X X D,H X 1.855.257.3932 www.merckaccessprogram-keytruda.com Pemetrexed Alimta Eli Lilly X X 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 Ribociclib Kisqali Novartis 1.800.282.7630 https://www.hcp.novartis.com/access Rituximab Rituxan Genentech X X D,H,P X 1.866.422.2377 www.genentech-access.com/hcp Rolapitant Varubi Tesaro, Inc. X X X 1.844.283.7276 https://www.togetherwithtesaro.com/ 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 Rucaparib Rubraca Clovis Oncology X X X 1.844.779.7707 http://rubracaconnections.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 http://www.provenge.com/reimbursement 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 X D,P,H,F,A,X X 1.877.744.5675 www.pfizerrxpathways.com Talimogene laherparepvec Imlygic Amgen X X X 1.888.427.7478 AmgenAssistOnline.com Tamoxifen Nolvadex H,M TBO-Filgrastim Granix Teva Oncology X X 1.888.587.3263 http://tevacore.com Telotristat Ethyl Xermelo Lexicon Pharmaceuticals Temozolomide Temodar Merck D 1.800.727.5400 www.merckhelps.com Temsirolimus Torisel Pfizer X P,H,F,A X 1.877.744.5675 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 Genzyme X X P X 1.800.367.4999 www.caprelsa.com/pt_resources_and_support.asp Valrubicin Valstar Endo Pharmaceuticals X Vemurafenib Zelboraf Genentech X X P X 1.866.422.2377 www.genentech-access.com/hcp Venetoclax Venclexta Genentech X X 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 2017 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 The foundation will contact periencing reimbursement issues, federal poverty guidelines, which patients and providers about the customer service representatives are adjusted each year. To apply: application within a week to let are available to assist. • Click on the medication patients know if they are approved (abbviepaf.org/apply.cfm). for assistance. If the application • Complete the application. was missing information the patient Fill out the sections completely and/or provider will be asked (please refer to the checklist to provide missing information. on the application). Once received, the foundation will • Attach proof of income evaluate the application. The foun- if required. dation will contact patients and • Be sure the patient and provider providers about the application to sign and date the application. let them know if the patient is now • If patient has Medicare Part D approved for assistance. and is applying for assistance, download and complete the If the patient is eligible for assis- appropriate attestation form. tance, a supply of the medication will be shipped to the prescriber’s office. It is the responsibility of the prescriber or office staff to reorder at least 7 business days prior to the patient requiring further medication.

26 / ACCC 2017 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), ImlygicTM (talimogene laherparepvec) suspension for intralesional injection, Kyprolis® (carfilzomib), Neulasta® (pegfilgrastim), Neupogen® (filgrastim), Nplate® (romiplostim), Prolia® (denosumab), Sensipar® (cinacalcet), Vectibix® (panitumumab), XgevaTM (denosumab)

Patient and Reimbursement Assistance Website amgenassist360.com

PATIENT ASSISTANCE that covers medication costs for benefit of $10,000 per patient the drugs listed above. Patients per calendar year. (For Prolia: Co-pay Assistance must not participate in any maximum benefit of $3,000 Support federal, state, or government- per patient per calendar year. Amgen offers co-pay coupon funded healthcare program, For Kyprolis: maximum benefit programs for Imlygic, Kyprolis, such as Medicare, Medicare of $20,000 per patient per Neulasta, Neupogen, Nplate, Advantage, Medicare Part D, calendar year.) Patient is re- Prolia, Vectibix, and Xgeva to Medicaid, Medigap, VA, DoD, sponsible for costs above these help eligible patients who are or TriCare. amounts. commercially insured with their • Patients may not seek reim- deductible, co-insurance, and/or bursement for value received Restrictions may apply. Amgen co-payment requirements. To from the Amgen FIRST STEP reserves the right to revise or confirm patient eligibility and Program from any third- terminate this program, in whole enroll in one of these programs, call party payers, including flexible or in part, without notice at any 1.888.65.STEP1 (888.657.8371) or spending accounts or healthcare time. This is not health insurance. visit amgenfirststep.com. savings accounts. Program invalid where otherwise prohibited by law. Register before Amgen FIRST STEP™ Coverage Limits any Amgen treatment. Program • Program covers out-of-pocket This financial support program medication costs for the Amgen Learn more at the Amgen FIRST helps commercially-insured eligible product only. Program does not STEP Co-pay Card Program Health patients with their co-pay and other cover any other costs related Care Provider Portal: https://amgen treatment costs. Patient eligibility to office visit or administration firststep.com/hcp. From the portal, requirements: of the Amgen product. Other healthcare providers can enroll restrictions may apply. patients, review records, download • Patients must be prescribed one • No out-of-pocket cost for forms, and upload documents. of the drugs listed above. first dose or cycle; $25 out- Questions? Call 1.888.65.STEP1 • Patients must have private of-pocket cost for subsequent (1.888.657.8371) Monday through commercial health insurance dose or cycle. Maximum Friday, 9:00 am to 8:00 pm EST.

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 27 TABLE OF CONTENTS Amgen

Uninsured Patients must complete the Product Prescrip- • Appeals Support Patients may be able to receive tion Form (safetynetfoundation. Appeals process information Amgen medications at no cost from com/pdf/RE-SNF-007-A-Product • Transportation and lodging The Safety Net Foundation (safety PrescriptionForm_V1.pdf) or cost assistance. Referral to netfoundation.com/index.html) if submit an original prescription. For third-party organizations for they meet the following eligibility replacement products, the facility those patients who qualify and requirements: must first enroll in The Safety Net need assistance with or help • Are a resident of the U.S. or Foundation (safetynetfoundation. paying for gas, lodging, tolls, its territories com/pdf/RE-SNF-002-P_V2_ and parking in connection with • Satisfy income eligibility Facility_Application.pdf). The receiving therapy. requirements facility can then submit requests • Patient and caregiver support • Have no or limited drug for replacement product using the services. Referral to support coverage Product Replacement Request Form services for patients, families, • Do not have any other (http://www.safetynetfoundation. and caregivers that provide insurance or financial support com/pdf/Product_Replacement_ product information, support options Form_3_28_16.pdf). Institutions group information, nutritional that have enrolled as Individual information, side effect man- NOTE: Qualifying Medicare Part D Patient Assistance Program (IPAP) agement, along with practical patients may also be eligible if they facilities may use the IPAP Patient matters related to the patient’s meet additional criteria demonstrat- Application (safetynetfoundation. condition. ing inability to afford medications com/pdf/RE-SNF-011-C_IPAP_ based on income. Patient_Application_UpdatedV3. Providers can enroll their patients pdf) to enroll their patients. online at: http://www.amgenassist To enroll in The Safety Net Foun- 360.com/hcp/. All services are dation, patients must meet program Questions? Call 1.888.762.6436. subject to eligibility requirements. eligibility requirements and The online form includes three complete the Patient Application Amgen Assist 360™ sections, and you should have the Form: This comprehensive, personalized following information available: • (English) http://www.safe- program provides information and tynetfoundation.com/pdf/ patient assistance for patients on Section 1. Patient Information Application_V12_Physician_ Blincyto and Kyprolis, including: 1. Your patient’s contact infor- Administered_English_ • Insurance Verification mation, including address and June_2016.pdf Verifying patient’s insurance phone number • (Spanish) http://www.safe- information and determining 2. Your professional contact tynetfoundation.com/pdf/ patient coverage responsibility information. Application_V12_Physician_ for services to be provided Administered_Spanish_ • Free product assistance for Section 2. Physician June_2016.pdf. uninsured patients or those Information rendered uninsured through 1. Your professional contact Please note: As of June 2016 all payer denial who meet certain information applications have been updated. income, medical, and eligibility 2. The referring physician’s Beginning October 1, 2016, criteria contact information outdated versions of this applica- • Independent foundation 3. Your state license, DEA tion will no longer be accepted. assistance. Co-pay and/or number, tax ID number, To get started, complete the Patient co- insurance assistance NPI/PTAN number, patient Application Form above. For through third-party diagnosis ICD-9 code, patient prescription products, physicians foundations dose, treatment start

28 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 29 TABLE OF CONTENTS Amgen

date, and previous patient therapy information. Communication Skills 101

Section 3. Insurance Effective communication is a two-way process involving listening and Information speaking. It is a learned skill that requires practice. Listening and speaking 1. Your patient’s insurance infor- are equally important to the process. To listen effectively, you must resist mation, including carrier, phone formulating your response while the other person is still speaking. The better number, policy ID, group num- option: allow a thoughtful pause while you both digest what has been said. ber, and subscriber’s date of birth. Tips for Effective Speaking Section 4. Free Product • Pay attention—not just to your words, but also to your non-verbal Assistance message(s). 1. Your patient’s current annual household adjusted gross • Putting a desk between you and the patient and family can foster a income perception of distance. If possible, position yourself at a 35 to 45 degree 2. Your patient’s federal tax angle towards the patient and keep your arms relaxed and open towards return, W2 form, or Social their body. Security benefit statement. • Try not to look tense or stressed, instead adopt a relaxed and calm You can also enroll patients by demeanor. Look up frequently to maintain eye contact. phone by calling 1.888.4ASSIST (1.888.427.7478) Monday through • DO smile, sit, or stand comfortably. Friday, 9:00 am to 8:00 pm EST. • Have at least 2 to 3 minutes of discussion with the patient and family before you begin to take notes. Never “doodle.” Shuffle papers as little REIMBURSEMENT as possible. The patient must feel that your focus is on him or her and ASSISTANCE what they are saying.

Amgen Assist 360™ • Allow patients and families to see your notes before the end of your visit. This comprehensive, personalized Remember: transparency builds trust. program provides information and reimbursement assistance for patients on Blincyto and Kyprolis, Source. ACCC Financial Advocacy Network. accc-cancer.org/FAN including: • Insurance verification. Verifying patient’s insurance informa- tion and determining patient coverage responsibility for services to be provided. • Appeals support.

Providers can enroll their patients online at: http://www.amgenassist 360.com/hcp/ (see the instruc- tions above) or by calling: 1.888.4ASSIST (1.888.427.7478) Monday through Friday, 9:00 am to 8:00 pm EST.

ACCC 2017 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 assessment. The Biologics multidis- coverage ARIAD has created ARIAD ciplinary pharmacy care team will: Assurance PASS. The plan is designed ARIAD PASS™ • Counsel your patient, including to ensure that patients who start To support your patients, a review of drug and food in- on treatment are able to stay on ARIAD has partnered with teractions, dosage, and possible treatment even if there’s a change in Biologics, an oncology pharmacy side effects their insurance status. For ARIAD that provides a comprehensive • Provide information on Assurance PASS, medication can be and personalized approach to sup- adherence and side effect man- provided at no cost for up to 90 days. porting patients throughout their agement support throughout There are three ways you can get prescribed therapy. Each of your therapy your patients access to ARIAD PASS: ARIAD patients will be assigned a • Coordinate with your patient Biologics Oncology Pharmacist and to set up free delivery and free 1. Call toll-free 1.855.447.PASS Nurse Specialist to provide clinical refill delivery based on your (1.855.447.7277) Monday support from receipt of prescription patient’s therapy schedule through Friday, 9:00 am to 6:00 throughout treatment. • Contact your office if a new pm EST prescription is needed 2. Visit ariadpass.com to Enrolling your patients in ARIAD • Advise your patients on how download the Prescription PASS is easy with the ARIAD PASS to take, store, and properly Form, then fax the completed Prescription Form found online dispose of medication. ARIAD PASS Prescription at: ariadpass.com/hcp.html, which Form to 1.855.557.PASS can be faxed to ARIAD PASS at The Patient Access Specialist (1.855.557.7277). 1.855.557.PASS (1.855.557.7277). provides eligible patients with an array of financial assistance REIMBURSEMENT A Patient Access Specialist will options, including co-pay or ASSISTANCE conduct a benefits investigation co-insurance support, based on and provide the results. The Patient their insurance coverage and ARIAD PASS Access Specialist will also work with financial needs. If your patient A Patient Access Specialist quickly patients who are unable to identify requires medication during a determines your patient’s level of programs or services for which coverage delay, the benefits coor- insurance coverage and any addi- they may be eligible. Once a benefits dinator can provide your patient tional requirements, such as prior investigation is complete, a Biologics with a one-time, 30-day supply to authorizations, so your patient can Oncology Pharmacist will contact ensure that they can start medica- promptly begin therapy. your patient to schedule delivery tion free of cost. If your patient has and perform an initial baseline a qualifying disruption in insurance

30 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 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 experienced an with an asterisk), including the insurance-related access delay Xtandi signatures section. (NOTE: It is • Have been prescribed Xtandi Support SolutionsSM critical that the enrollment form for an FDA-approved Xtandi Support Solutions is signed by both the prescrib- indication. (astellaspharmasupportsolutions. ing doctor and the patient or the com/products/xtandi) provides patient’s authorized representative.) Xtandi Quick Start+ Program services to help patients and Return by fax to 1.855.982.6341. allows your patient to start their healthcare providers with access Xtandi treatment while Xtandi and reimbursement, and informa- Xtandi Quick Start+TM Support Solutions or a network tion regarding coverage options Program specialty pharmacy works with and financial assistance programs. The Xtandi Quick Start+ Program the patient’s insurer to resolve co- Xtandi Support Solutions offers: provides a free, one-time 14-day verage issues. • Instructions for filling out supply of Xtandi to new patients the Xtandi Solutions patient who experience a delay in insu- Commercially enrollment form rance coverage. Providers should Insured Patients • Benefits verification complete the Quick Start+ Program The Xtandi Patient Savings Program • Prior authorization requests portion of the Patient Enrollment is for patients who have commercial • Assistance with appeals when Form so their patients will be and/or private health insurance prior authorization requests eligible for the program if needed. but who may have trouble paying are denied If prescriptions are not filled within their out-of-pocket costs. Under • Xtandi Quick Start+ Program 7 business days due to insurance this program: • Patient assistance coverage delays, Xtandi Support • Patients should expect to pay no • Specialty pharmacy Solutions assesses the case for eli- more than $20 per prescription coordination. gibility. A 14-day supply of Xtandi • Co-pay assistance is available is shipped overnight directly to the for up to 12 refills To enroll your patient in Xtandi patient. • Your patient is covered for Support Solutions, complete the savings up to $5,000 for each Patient Enrollment Form In order to be eligible for the prescription and a maximum (astellaspharmasupportsolutions. Quick Start+ program, patients savings up to $25,000 per year com/docs/xtandi/XSS_Patient_ need to: • There are no income Enrollment_Form.pdf) in its • Be new to Xtandi therapy requirements.

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 31 TABLE OF CONTENTS Astellas

The program is not available to Xtandi Support Solutions can • Help determine what type of patients who have prescription determine whether a patient meets cost-sharing the patient has, drug coverage paid in part or in full these criteria. To enroll a patient with such as a flat co-payment or a under any state or federally funded the Astellas Access Program, com- percentage-based co-insurance programs, including but not limited plete the Xtandi Support Solutions • Evaluate eligibility for Medicare to Medicaid, Medicare, Medicare Patient Enrollment Form (including Part D patients who may qualify Part D, Medigap, DoD, VA, the signatures section of this form) for the Low-Income Subsidy (LIS) TRICARE, or any state patient or (astellaspharmasupportsolutions. • Help determine whether a pharmaceutical assistance program. com/docs/xtandi/XSS_Patient_ patient is eligible for assistance Enrollment_Form.pdf) and fax it from an independent co-pay To enroll your patient in Xtandi to 1.855.982.6341. Retain a copy foundation. Patient Savings Program, complete of your patient’s proof of income, the Xtandi Support Solutions which may include one of the REIMBURSEMENT Patient Enrollment Form following: ASSISTANCE (astellaspharmasupportsolutions. • Copy of the patient’s most com/docs/xtandi/XSS_Patient_ recent tax return Xtandi Support Enrollment_Form.pdf), including • Copy of the patient’s most Solutions all patient and healthcare provider recent W-2 form Specialists are available to help signatures, and fax the completed • Copy of the patient’s 1099 patients find the best option to form to 1.855.982.6341 or contact Social Security form gain rapid access to Xtandi. Xtandi your preferred network specialty • Copy of the patient’s most recent Support Solutions can help with: pharmacy to determine eligibility Social Security benefits letter • Reimbursement support (benefit and enroll in the program. • Copy of the patient’s latest verification, prior authorization pay stubs for 4 consecutive tracking, appeal assistance) Uninsured Patients pay periods. • Prescription triage to a specialty The Astellas Access Program is pharmacy in the Xtandi Support for patients without prescription Once your patient is approved for Solutions network coverage for Xtandi. The program assistance under the Astellas Access • Questions on using specialty provides free Xtandi to patients Program, Xtandi Support Solutions pharmacies who qualify. Eligibility is deter- will notify both the prescriber and • Support for in-office dispensers mined on a patient-specific basis. patient. A 30-day supply of Xtandi • Referrals to programs to help To be eligible for the Astellas Access is then shipped directly to the with out-of-pocket expenses Program patients must meet the patient’s home each month they • Facilitating immediate access following criteria: are enrolled in the program. to Xtandi via the Quick Start+ • Patient is uninsured or has program insurance that has denied Medicare Patients • Determining patient eligibility coverage for Xtandi Medicare typically covers Xtandi for the Astellas Access Program. • Patient has a verifiable shipping under the Medicare Part D pre- address in the United States scription drug benefit. However, • Patient has been prescribed a patient’s cost share may vary, Xtandi for an FDA-approved depending on their Medicare plan. indication Xtandi Support Solutions can • Patient has an annual adjusted help evaluate a Medicare patient’s gross household income of less financial need and assistance options. than $100,000 per year. Xtandi Support Solutions can:

32 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 33 TABLE OF CONTENTS Astellas

Benefits Verification Xtandi Support Solutions will • Submit, track, and view the Xtandi Support Solutions performs submit the completed form to results of Astellas Access the benefits verification upon receipt the patient’s insurer. Program℠applications. of the Patient Enrollment Form. After performing a comprehensive At the request of the healthcare Go to https://eservice.astellasaccess. assessment of patient coverage for provider, Xtandi Support Solutions com/ to get started with Astellas Xtandi, Xtandi Support Solutions will follow up with the patient’s Access eService. provides patients with a summary insurer to confirm receipt of the of benefits that includes: prior authorization form, check • The patient’s insurance coverage on the status of the form, and requirements for Xtandi determine the outcome. Xtandi • Requirements for prior Support Solutions will follow authorization, step edit, or up with the healthcare provider other coverage restrictions regarding the prior authorization • Cost-sharing responsibility, results, inform them if any addi- including deductibles, tional information is required, co-insurance or co-payment, and assist with denial appeals and out-of-pocket maximums as necessary. • A list of specialty pharmacies that participate in your patient’s Prior Authorization insurance coverage. Denial Appeals If a patient’s insurer denies a claim Xtandi Support Solutions will send or prior authorization request, your office a summary of benefits Xtandi Support Solutions can assist typically within 2 hours of receipt with the appeals process by: of the Patient Enrollment Form. • Identifying the reason for the denied claim or prior authoriza- Prior Authorization tion request Xtandi Support Solutions will • Determining the additional determine whether a patient’s required documentation plan requires prior authorization • Informing the healthcare for Xtandi, and if it does, how to provider what information is obtain the prior authorization. needed and where to send the Xtandi Support Solutions will also: appeal • Provide a summary of prior • Tracking and relaying the status authorization requirements and of the appeal. obtain the appropriate prior authorization form Astellas Access • Pre-populate the prior authori- eService Portal zation form using the informa- The Astellas Access eService tool is tion provided on the patient an interactive website for healthcare enrollment form providers to securely and efficiently • Send the form to the healthcare submit, track, and manage requests provider to complete and sign online. Available 24 hours a day, • If the healthcare provider eService allows providers to: returns the completed form • Submit, track, and view the to Xtandi Support Solutions, results of benefit verifications

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 33 TABLE OF CONTENTS AstraZeneca

AstraZeneca

Products: Faslodex® (fulvestrant) Injection, Imfinzi™ (durvalumab) Injection, Iressa® (gefitinib) Tablets, Lynparza™ (olaparib) Capsules, Tagrisso® (osimertinib) Tablets

Patient and Reimbursement Assistance Websites astrazenecaspecialtysavings.com MyAccess360.com

PATIENT ASSISTANCE Patient Savings Program via support, and information about af- AstraZeneca has a commitment to the online enrollment portal. fordability programs for providing affordable access to its The links to the portal for each AstraZeneca’s medicines. medications and wants to ensure product can be found at that cost is not a barrier when a astrazenecaspecialtysavings.com. This program helps patients and physician has determined that an 3. A Patient Savings Program providers with: AstraZeneca medication is account will be created for the • Identifying and understanding appropriate for a patient. eligible patient. Once enrolled, prescription coverage, patient-specific account out-of-pocket costs, and Patient Savings Programs for information will be presented in pharmacy options FASLODEX, IRESSA, LYNPARZA, the portal for immediate use. • Prior authorization support and TAGRISSO help eligible, 4. The patient will pay a • Pharmacy coordination commercially insured patients set amount of his or her • Reimbursement process with the out-of-pocket costs of their out-of-pocket costs, based on • Denial and appeal support prescriptions. Patients enrolled the product. The pharmacy or • Connecting to patient savings in government-funded healthcare provider will use the Patient programs programs such as Medicare, Savings Program to cover the • Referring patients to patient Medicaid, Medigap, Veterans balance, up to the program assistance programs Affairs (VA), or TRICARE are not maximum. • Connecting to nurse eligible for AstraZeneca's patient For more information about assistance or educational savings programs. eligibility and details on these support programs, if applicable programs, please visit (not for all medicines) How the Programs astrazenecaspecialtysavings.com The program is staffed with Work: or call AstraZeneca Access 360 at knowledgeable AstraZeneca 1. Your patient may have an 844.ASK.A360 (844.275.2360). Reimbursement Counselors who out-of-pocket cost for an are available at 844.ASK.A360 AstraZeneca treatment. AstraZeneca Access (844.275.2360) Monday-Friday, 2. If the patient meets the 360™ Program 8:00 am-8:00 pm EST. For eligibility requirements, you AstraZeneca Access 360™ provides additional information, visit can enroll him or her into the patient access, reimbursement MyAccess360.com.

34 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 35 TABLE OF CONTENTS AstraZeneca

The AZ&Me™ medication while application is Patients with Medicare Prescriptions Savings being processed Part D Programs • Applications accepted via Program Highlights The AZ&Me™ Prescriptions phone, fax, or mail • AstraZeneca medicines Savings Programs are designed to • Annual enrollment; patients provided at no cost help qualifying people without may re-enroll after 12 months • Medicines mailed to patient’s insurance and those in Medicare if eligible home or physician’s office Part D who are still having trouble • Up to 30 days of product affording their AstraZeneca medi- Eligibility Requirements provided for each fill cations. There are two programs: • Patient must be without • Qualified patients provided • AZ&Me Prescription Savings prescription drug coverage with a temporary enrollment program for people without through private insurance or and up to 30 days’ supply of insurance government programs medication while application • AZ&Me Prescription Savings • Patient must have annual gross is being processed program for people with household income at or below • Applications accepted via Medicare Part D $100,000* phone, fax or mail • Patient must be a legal US • Enrollment is by calendar year; There is a shared application resident patients are enrolled until 12/31 process for the AZ&Me • Patient must not be eligible of the current year and may Prescription Savings program for Medicaid in their state of re-enroll if eligible for people without insurance and residence the AZ&Me Prescription Savings Eligibility program for people with Medicare Application Checklist Requirements Part D, and the same application is The following items must be • Patient must be enrolled in a used for both programs. To apply submitted in order to complete Medicare Part D Plan for the program you may either call enrollment in the program: • Patient must have annual gross 1.800.AZandMe (1.800.292.6363) • A completed application signed household income at or below or visit azandmeapp.com to and dated by the patient and $100,000* download an application. For an prescriber • Patient must have spent 3% or updated list of the medications • A completed prescription more of total household income available through the AZ&Me (included on page 3 of the on prescription medicines Prescription Savings Program, application) through a Medicare Part D please visit azandmeapp.com. • Proof of household income Prescription Drug Plan during the current year Patients without Please note that faxed applications • Patient must not be eligible for Insurance must be sent from a physician’s LIS (“extra help”) Program Highlights office in order for their prescription • Patient must be a legal US • AstraZeneca medicines to be processed. resident provided at no cost • Patient must not be eligible for • Medicines mailed to patient’s * Income eligibility criteria for Medicaid in their state of home or physician’s office some products may be different residence • Up to 30 days of product from the income level listed above. provided for each fill For more information, please visit • Qualified patients provided azandmeapp.com or call 1.800. with a temporary enrollment AZandMe. and up to 30 days’ supply of

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 35 TABLE OF CONTENTS AstraZeneca

Application Checklist The following items must be submitted in order to complete enrollment in the program: • A completed application signed and dated by the patient and prescriber • A completed prescription (included on page 3 of the application) • Proof of household income • A copy of the front and back of the patient’s Medicare Part D Plan Card • A copy of the patient’s Medicare Part D Prescription Drug Plan statement (Explanation of Benefits [EOB]), a pharmacy printout, or a summary document from a pharmacy indicating the amount spent on prescriptions in the current calendar year; this total should be at least 3% of the patient’s income

Please note that faxed applications must be sent from a physician’s office in order for their prescription to be processed.

*Income eligibility criteria for some products may be different from the income level listed above. For more information, please visit azandmeapp.com or call 1.800.AZandMe.

36 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 37 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. this form, the patient gives per- Registered users can also submit an mission for the program to pay Xofigo Access Services application for patient assistance via co-pay/co-insurance assistance Uninsured Patients the secure Xofigo Access Services funds directly to the provider. Once You must apply for assistance on Provider Portal: approved, your patient receives an your patient’s behalf by submit- xofigoaccessonline.com. approval letter with a Commercial ting a completed application (hcp. Co-pay/Co-insurance Assistance xofigo-us.com/downloads/PP- Co-Pay Assistance for identification (ID) card. Patients 600-US-1278_Xofigo_Access%20 Patients with Private approved for assistance will not Services%20PAP_Copay%20App_ Commercial Insurance have to pay anything to access Digital.pdf), including a signed You must apply for assistance on Xofigo. Call an Access Counselor at patient authorization. Eligibility your patient’s behalf by submitting 1.855.6XOFIGO (1.855.696.3446), criteria include: a completed application, including 9:00 am to 8:00 pm EST, Monday • Financial criteria based on a signed patient authorization. through Friday, if you have any adjusted gross household Eligibility criteria include: questions or to obtain more infor- income (documentation of • Financial criteria based on mation. Registered users can also income is required) adjusted gross household submit an application for patient • Residency in the United States, income (documentation of assistance via the secure Xofigo including the District of income is required) Access Services Provider Portal: Columbia, Puerto Rico, Guam, • Residency in the United States, xofigoaccessonline.com. or the U.S. Virgin Islands including the District of • Treatment provided in an Columbia, Puerto Rico, Guam, Co-Pay Assistance for Patients outpatient setting. or the U.S. Virgin Islands Insured by Public Payers • Treatment provided in an Medicare beneficiaries and patients Call an Access Counselor at outpatient setting. with other government insurance 855.6XOFIGO (1.855.696-3446), who need help paying for treatment 9:00 am to 8:00 pm EST, Monday You and your patient must sign and with Xofigoare not eligible for through Friday, if you have any submit the Application for Patient co-pay assistance through Xofigo questions or to obtain more infor- Assistance/Commercial Co-pay Access Services. These patients may mation. Fax a completed applica- Assistance that includes a signed be eligible for co-pay or co-insur- tion, including the signed patient patient authorization. By signing ance assistance through an indepen-

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 37 TABLE OF CONTENTS Bayer HealthCare

dent co-pay assistance foundation. • Enroll at: these services online 24/7 through If co-pay assistance needs are zerocopaysupport.com the Xofigo Access Services Provider identified, a Xofigo Access Services • Obtain BIN & Group # and Portal: xofigoaccessonline.com. Or Access Counselor can provide in- provide to your pharmacist. download the Quick Reference formation about other foundations Call 1.866.581.4992 for more Reimbursement Guide Hospital that will determine a patient’s eligi- information on enrolling online. Outpatient and Quick Reference bility for co-pay or co-insurance Reimbursement Guide Freestanding assistance based on their own criteria. Government Insured Center forms at: https://xofigoac- • Information on Part D cessonline.com/StaticPageContent. REACH® prescription drug plans aspx?Category=StaticReimburseme Patients taking Stivarga or Nexavar • Financial assistance may be ntForms. can enroll in REACH® (Resources available through independent for Expert Assistance and Care charitable organizations REACH® Helpline). This free program is here • Alternate funding options. Some insurance plans require patients to support patients and caregivers Call 1.866.639.2827 to speak with to obtain approval for coverage before with information about therapy and a reimbursement counselor starting therapy (known as Prior Au- financial assistance options. (9:00 am-5:00 pm EST). thorization), which can take time and delay the start of therapy. REACH The REACH program offers: Uninsured/Underinsured may be able to provide temporary Nurse Counselors to answer • Patient Assistance Program assistance for patients to start medical questions and provide (PAP) therapy right away while waiting for educational and support materials, • Eligibility requirements apply their Prior Authorization approval. as well as guidance on side effects, • Up to 12 months of free drug and Financial Access Counselors to for qualified patients The REACH program has Nurse provide help with: • Alternate funding options. Counselors to answer medical • Benefit verification and specialty Call 1.866.639.2827 to speak with questions and provide educational pharmacy provider (SPP) a reimbursement counselor and support materials, as well identification (9:00 am-5:00 pm EST). as guidance on side effects, and • Patient Assistance Program Financial Access Counselors to (PAP) for the uninsured or REIMBURSEMENT provide help with: underinsured ASSISTANCE • Benefit verification and specialty • Prior authorizations and denial/ pharmacy provider (SPP) appeal information XOFIGO ACCESS identification • Co-pay assistance for eligible SERVICES • Patient Assistance Program commercially insured patients Comprehensive reimbursement (PAP) for the uninsured or not previously enrolled in the assistance, including: underinsured REACH Commercial Co-Pay • Insurance benefit verifications • Prior authorizations and denial/ Assistance Program • Prior authorization support appeal information • Alternative coverage research • Claims appeal research and • Co-pay assistance for eligible • Referral to independent or- information commercially insured patients ganizations that may assist • Claims tracking not previously enrolled in the eligible patients with their • Billing and coding information REACH Commercial Co-Pay out-of-pocket • Payer policy information. Assistance Program • Alternative coverage research Privately Insured Patients To access these services, call • Referral to independent organi- • No monthly cap 1.855.6XOFIGO (1.855.696.3446) zations that may assist eligible • Up to $25,000 per year 9:00 am to 8:00 pm EST, Monday patients with their out-of-pocket through Friday. You can also access expenses.

38 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 39 TABLE OF CONTENTS Boehringer Ingelheim

Boehringer Ingelheim Pharmaceuticals, Inc.

Oncology-related product: Gilotrif™ (afatinib)

Patient and Reimbursement Assistance Website gilotrifhcp.com/solutions-plus/access-reimbursement

PATIENT ASSISTANCE BI Cares Foundation. (NOTE: This helpful kit includes the patients must be U.S. residents.) following patient resources: Solutions Plus™ • My Guide patient brochure This program offers a range of To determine if a patient is eligible • My Diary treatment journal services to help alleviate financial for programs offered by or through • Topical lotion and loperamide concerns around access. Insurance Solutions Plus, BI Cares Founda- (OTC) samples. coverage should not be a barrier to tion, or other support programs, cancer treatment—we will explore please reference Gilotrif access and Gilotrif Dose Exchange™ multiple options to help a variety reimbursement tools at: https:// https://www.gilotrifhcp.com/ of patients afford their treatment, gilotrifhcp.com/solutions-plus/access- solutions-plus/clinical-support# including: reimbursement#coverage-and-reim- gilotrif-dose-exchange. • Commercially insured patients bursement. Or enroll your patient who are eligible pay no more by calling 1.877.814.3915, 8:00 am Gilotrif Dose Exchange is designed than a $25 co-pay per month to 8:00 pm EST or by downloading to help facilitate dose adjustments. through the Co-pay Assistance the application at: https://www.gilo It is offered to patients who Program. (NOTE: patients must trifhcp.com/sites/default/files/pdfs/ meet the following eligibility be U.S. residents.) PC-GF-0328-PROF_Solutions_Plus_ requirements: • Publicly insured patients are Enrollment_Form_Squamous.pdf. • Serviced through our dedicated connected to alternative funding specialty pharmacy partner, support, which may help offset Complete the entire enrollment form Accredo, or the Gilotrif co-pays, deductibles, or other with a signed patient authorization Dispense Network treatment-related expenses. If form and Gilotrif prescription and • For patients exchanging ≥9 denied alternative funding, fax it to: 1.866.240.4556. Fax con- tablets. publicly insured patients may be firmation will be provided within 2 eligible for BI Cares Foundation hours of enrollment form submission. Here's how the Gilotrif Dose support. (NOTE: patients must Exchange facilitates transition to be U.S. residents.) To help with Gilotrif treatment ini- new dose: • Uninsured and underinsured tiation and continued adherence, all • Eligible patients sent new dose patients who have been denied patients taking Gilotrif will receive promptly once their oncologist financial assistance from other a Patient Support Kit (https://www. submits new prescription foundations may be eligible for gilotrifhcp.com/solutions-plus/ • Covers up to 2 dose free medication through the clinical-support#patient-support-kit). modifications

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 39 TABLE OF CONTENTS Boehringer Ingelheim

• Patients can easily return • Five outbound calls will be To get patients started on therapy unused drug using the prepaid made to patients as easily and quickly as possible envelope that is sent with the • Treatment-related adverse and minimize reimbursement chal- replacement dose. events education and tips for lenges, Solutions Plus provides adherence are addressed assistance with: The Exchange also eliminates addi- • Language interpreter service • Benefit verification. Upon tional co-pays in a given month: available in 170 languages. enrollment, reimbursement • Insurers will not be billed, and specialists investigate and patients will not be charged a Oncology-trained nurses are also verify coverage for patients co-pay for replacement drug. available to answer questions as within 2 business days from needed. Contact Solutions Plus initiation. How Gilotrif Dose ExchangeTM at 1.877.814.3915, 8:00 am-8:00 • Prior authorization. Reimburse- works: pm ET. Solutions Plus® keeps your ment specialists anticipate and • Patient serviced through practice informed throughout communicate prior authoriza- Accredo or the Gilotrif Dispense each patient's participation in the tion requirements for payers. If Network is prescribed a new program. When a nurse speaks prior authorization is needed dosing strength of Gilotrif to a patient about treatment with and the patient receives Gilotrif (afatinib) tablets and ≥9 pills Gilotrif, your office receives a fax tablets from our dedicated remain in old dose. update. specialty pharmacy partner, • Oncologist provides new Accredo, then Solutions Plus prescription to Solutions Pharmacy support: Dedicated may assist with submission and Plus on the designated enroll- Gilotrif professionals are available tracking of prior authoriza- ment form. for patients and physicians who tion consistent with health plan • Solutions Plus confirms Gilotrif have questions related to Gilotrif. requirements. Dose Exchange eligibility. Physicians and healthcare practice • Gilotrif Bridge. If a patient • Accredo or a central pharmacy professionals may connect directly experiences a payer delay at Solutions Plus sends new with Gilotrif-trained pharmacists of more than 7 days for the dose and prepaid return with Accredo. Call 1.844.569.2837 FDA-approved indication, they envelope to patient; health from 8:30 am-7:00 pm ET or may receive a 15-day supply of plan is not billed and patient fax 1.888.454.8488. Patients can Gilotrif tablets. This program is not charged a second co-pay reach Patient Care Advocates and allows patients to start therapy for the new prescription. Gilotrif-trained nurses with and avoid a prolonged delay. • Patient returns pills remaining Accredo by calling 1.844.569.2836 NOTE: This program is for from old dose using prepaid from 8:00 am-8:00 pm ET. commercially and publicly envelope provided by insured patients treated with Solutions Plus. REIMBURSEMENT Gilotrif for the FDA-approved ASSISTANCE indication. Nurse and Pharmacy • Denials & appeals. Support Solutions Plus Reimbursement specialists Nurse support: Real-time patient This program helps providers and follow up with programs when education and assistance to comple- patients navigate coverage and patient claims are denied, and ment care. Oncology-trained nurses reimbursement challenges. Knowl- Boehringer Ingelheim Access will call participating Gilotrif edgeable reimbursement specialists Reimbursement and Distri- patients during critical time points assist with the coverage and reim- bution Managers provide of NSCLC treatment to assist with bursement process throughout the additional support with the adherence. patient’s Gilotrif treatment journey. appeals process.

40 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 41 TABLE OF CONTENTS Boehringer Ingelheim

Providers can obtain a Solutions Plus enrollment form by calling 1.877.814.3915, 8:00 am to 8:00 pm EST or download the applica- tion at: https://www.gilotrifhcp. com/sites/default/files/pdfs/PC-GF- 0328-PROF_Solutions_Plus_Enroll ment_Form_Squamous.pdf.

Complete the entire enrollment form with a signed patient autho- rization form and Gilotrif prescrip- tion and fax it to: 1.866.240.4556. Fax confirmation will be provided within 2 hours of enrollment form submission.

Distribution Solutions Plus® works closely with Accredo, our single, dedicated, specialty pharmacy partner, to ensure: • Timely distribution • Seamless transition from enroll- ment to prescription fulfillment • Consistent support experience for patients.

Gilotrif is also available at select on-site pharmacies: • Select, large group practices • Kaiser Permanente® • NCI-designated Cancer Centers • Select hospitals with outpatient clinics • Integrated delivery networks • Veterans Administration/ Department of Defense.

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 41 TABLE OF CONTENTS Bristol-Myers Squibb

Bristol-Myers Squibb

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

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

PATIENT ASSISTANCE combination of those two medica- When completing the form, check tions will be treated as one dose, the box for the BMS Oncology BMS Access Support™ requiring the patient pay only $25 Co-Pay Program. BMS Access Bristol-Myers Squibb (BMS) Access of the medications' co-pay for that Support determines patient eligibil- Support can help identify financial day. BMS will cover the remaining ity, including verifying commercial assistance programs for eligible amount up to $25,000 per year per insurance coverage to establish the patients who need help managing product, or $50,000 per year for appropriate benefit amount. BMS the cost of treatment. The appro- two BMS products administered Access Support then notifies the priate program will depend on the in combination. Other restrictions provider and patient of enrollment patient’s coverage. may apply. Final determination of and the appropriate next steps. program eligibility is based upon Finally, the provider submits the BMS Oncology review of completed application. primary claim to the commercial Co-Pay Program insurance carrier. If the Explanation This program (bmscustomer Enrollment is simple. The provider of Benefits form indicates that your connect.com/bmsaccesssupport/ collects the patient’s name, address, patient has a cost-sharing expense, oncology/services/patient-financial insurance carrier, and member notify BMS Access Support and -assistance/copay) is designed to identification number. The provider submit the required documentation assist with out-of-pocket co-pay, then completes the application to initiate appropriate next steps. deductible, or co-insurance costs through BMS Access Support in one For questions or to confirm receipt for eligible, commercially insured of the following ways: of the application, call the Support patients who have been prescribed • Use the BMS Access Support Center at 1.800.861.0048, 8:00 am certain BMS products. Patients with Form Wizard. to 8:00 pm EST, Monday through state or federally-funded insurance • Download the enrollment Friday. plans are not eligible for this co-pay form on your computer and program. Enrolled patients pay fax to 1.888.776.2370. Assistance for the first $25 of their co-pay per • Enroll online with our Uninsured Patients infusion. If the patient receives secure portal: For patients without prescription two BMS medications covered by MyBMSOncologyCases.com. drug insurance, or for patients that this Program on the same day, the are underinsured, BMS Access

42 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 43 TABLE OF CONTENTS Bristol-Myers Squibb

Support can refer them to indepen- However, there are independent secure portal: dent charitable foundations that foundations that can help. BMS MyBMSOncologyCases.com. may be able to provide financial Access Support can refer providers support, including, the Bristol-Myers to the foundation offering the best If you have further questions, you Squibb Patient Assistance Founda- support for their specific patient can contact a BMS Access Support tion (BMSPAF): bmspaf.org. This and help them through the applica- Care Coordinator. BMS Access charitable organization provides tion process. It is important to note Support Care Coordinators are medicine, free of charge, to eligible, that these foundations are indepen- always local. That means a famil- uninsured patients who have an dent and not affiliated with Bristol- iarity with your office, know- established financial hardship. The Myers Squibb. Each foundation has ledge of your patients’ cases, and BMSPAF accepts the BMS Access its own eligibility criteria and evalu- experience with the insurers in your Support application. Patients may ation process. Bristol-Myers Squibb area. Program Care Coordinators be eligible for assistance through cannot guarantee that a patient are available to your oncology the BMSPAF if they: will receive assistance. For details, office Monday through Friday, 3 Do not have insurance contact BMS Access Support at from 8:00 am to 8:00 pm EST at coverage, or have been denied 1.800.861.0048. 1.800.861.0048. coverage for a requested medicine REIMBURSEMENT BMS Access Support: 3 Are enrolled in a Medicare ASSISTANCE Prior Authorization Part D plan and have spent at Assistance least 3 percent of their yearly BMS Access Support: BMS Access Support can provide income on out-of-pocket costs Benefits Investigation plan-specific prior authorization for prescription medicines in the From the moment a treatment forms when one is required by the current year plan is determined, BMS Access patient’s health plan. Some health 3 Are being treated on an outpa- Support is here to help you stream- insurers require that a prior autho- tient basis line your patients’ experience. rization be issued before certain 3 Live in the United States, Puerto BMS Access Support can review items or services are covered. This Rico, or the U.S. Virgin Islands patients’ insurance coverage for may require specific forms and 3 Meet the income limits for the Bristol-Myers Squibb products and supporting documents before a requested medicine. help identify additional sources prior authorization may be issued of support. To begin the benefits (e.g., medical history, physicals, These are just some of the eligibil- investigation process: pathology reports, etc.). When ity requirements. Other eligibil- • Use the BMS Access Support necessary, make sure your patients ity criteria may apply. For more Form Wizard. Or download the understand coverage for the service information about eligibility and enrollment form at: before they have a financial obliga- to obtain an enrollment applica- bmsaccesssupport.bmscustomer tion to their provider. Please note: tion, call the Bristol-Myers Squibb connect.com/oncology/services/ If a prior authorization requirement Patient Assistance Foundation, at benefits-investigation. is not met, some health insurers 1.800.736.0003. • For questions or to confirm may deny coverage, even if the receipt of the application, claim would have otherwise been Assistance for Patients call the Support Center at covered. If coverage is denied, with Federally-Funded 1.800.861.0048, 8:00 am either the physician or the patient Insurance Plans to 8:00 pm EST, Monday may appeal. See below for details Patients with federally-funded through Friday. on prior authorization appeals. insurance plans are not eligible • You can also enroll, track, for co-pay assistance programs and manage your cases online Some insurers will make a predeter- sponsored by Bristol-Myers Squibb. with the BMS Access Support mination of coverage decision upon

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 43 TABLE OF CONTENTS Bristol-Myers Squibb

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

44 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 45 TABLE OF CONTENTS Celgene Oncology

Celgene Oncology

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

Patient and Reimbursement Assistance Website celgenepatientsupport.com

PATIENT ASSISTANCE • Commercial or private • Your patients must meet Celgene Patient Support® provides: insurance that does not cover specified financial and eligibil- • A single specialist assigned to the full cost of the prescribed ity requirements to qualify for help patients in your geographic Celgene medication assistance area • Residence in the United States • Assistance with understanding or a US territory Independent patient insurance coverage for • Patients with government Third-Party Celgene medications healthcare insurance (for Organizations • Information about financial example, Medicaid, Medicare For patients who are unable to assistance for prescribed [Parts B, C and D], Medigap, afford their medication (including Celgene medications TriCare are not eligible) patients with Medicare, Medicaid, • Other eligibility requirements or other government-sponsored Celgene Commercial and restrictions apply. Please insurance), Celgene Patient Co-Pay Program see full Terms and Condi- Support® can provide you with This program is for eligible tions on the Celgene Patient information about independent patients with commercial or private Support® website (https:// third-party organizations that may insurance (including healthcare media.celgenepatientsupport. be able to help patients with the exchanges). com/wp-content/uploads/ cost of: • Provides assistance to help Full-_Terms_and_Conditions_ • Deductibles patients meet co-pay/co-insur- Dec_2016_v.5Final.pdf) • Co-payments/co-insurance ance costs • Insurance premiums • Reduces co-pay responsibility Celgene Patient to $25 or less for the prescribed Assistance Program Financial and medical eligibility Celgene medication (PAP) requirements vary by organization. The Celgene Patient Assistance Eligibility criteria for patients Program is for qualified patients include: who are uninsured or underinsured. • Gross annual household income • Celgene medications may be of $100,000 or less (patients available at no cost to patients may be subject to a random who meet insurance and audit to verify income) financial criteria

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 45 TABLE OF CONTENTS Celgene Oncology

Transportation Prior Authorization/ Enrolling in Celgene Assistance Precertification Patient Support® Celgene Patient Support® can Assistance We have 3 simple ways for you to provide information about financial • Assist with the prior authoriza- enroll in Celgene Patient Support®. assistance for transportation costs tion or precertification process Choose the way that is easiest to and from medical appointments. by providing the necessary for you. • Independent third-party forms for completion • Enroll online now: You can organizations may be able to • Follow up with the insurance enroll patients in Celgene help patients with transporta- provider to determine the Patient Support® online tion costs, such as gasoline, outcome at www.celgenepatient parking, tolls, and taxi, bus, or • Celgene provides a facilitation support.com train fare, to and from medical service and will not provide • Call 1-800-931-8691: Patients appointments. any medical input into a prior can be enrolled over the phone authorization at 1-800-931-8691, Monday Financial and medical eligibility –Thursday, 8 AM – 7 PM ET, requirements vary by organization. Appeals Assistance and Friday, 8 AM – 6 PM ET • Provide information about the (translation services available) REIMBURSEMENT appeals process after a denied • E-mail or fax the enrollment ASSISTANCE prior authorization, precertifica- form: Download the English At the request of the patient, tion, and/or claim or Spanish enrollment form specialists are available to assist • Supply a checklist of the at www.celgenepatientsup- with each of the following steps in required documentation for port.com and return it to us the insurance approval process for submission to the insurance by e-mail at patientsupport@ prescribed Celgene medications. company celgene.com or fax it to us at Celgene cannot provide insurance • Submit the appeal to the 1-800-822-2496 advice or make insurance decisions. insurance company at the request of the patient and Benefits Investigation follow up on the status until • Initiate a benefits investigation a decision is reached to determine co-payment and • Celgene provides a facilitation other out-of-pocket costs service and will not provide any • Assess prior authorization or medical input into an appeal precertification requirements • Educate patients about insurance coverage or other programs for which they may qualify

46 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 47 TABLE OF CONTENTS Eisai

Eisai Co., Ltd

Oncology-related products: Aloxi® (palonosetron hydrochloride), HalavenTM (eribulin mesylate), Lenvima (lenvatinib) Capsules

Patient and Reimbursement Assistance Website eisaireimbursement.com

PATIENT ASSISTANCE Pay $0 Savings If you have prescribed Halaven Program there is a multi-step enrollment The Eisai Patient Commercially insured patients process, outlined below: Assistance Program prescribed certain Eisai medica- Certain Eisai medications may be tions may be eligible for the Eisai Step 1: Complete and submit an available at low-or-no cost to finan- Pay $0 Savings Program. Under enrollment form (http://www. cially needy patients who satisfy eli- this program commercially insured eisaireimbursement.com/-/media/ gibility criteria. To learn more call patients pay a $0 co-pay on each Files/XRay/Halaven/Halaven-0 1.866.61.EISAI (1.866.613.4724). prescription with an annual limit. Copay-Enrollment-Form.pdf) The same program enrollment Limits vary depending on the Eisai signed by both you and your form is used for all eligible Eisai medication you have prescribed. patient. products. You can download the • For patients prescribed form here: http://www.eisaireim Halaven, the maximum benefit Step 2: If the patient is determined bursement.com/-/media/Files/XRay/ paid by Eisai Inc. will be to be eligible they will be sent a Aloxi/Patient-Assistance-Enroll- $18,000 per year. Welcome Letter and a card. This ment-Form.pdf. • For patients prescribed card should be given to your office Lenvima, Eisai Inc. provides up so that it can be used to process the The Eisai insurance verification to $40,000 per year to assist virtual debit card payment. form (also used for all Eisai medi- with out-of-pocket costs. cations) can be downloaded here: Step 3: Fax the Explanation of http://www.eisaireimbursement. The enrollment process also varies Benefits (EOB) or detailed Specialty com/-/media/Files/XRay/Aloxi/ depending on the Eisai medication Pharmacy receipt for the Halaven Insurance-verification-form.pdf. that has been prescribed. claim to 844.745.2350. The following information should be If you have prescribed Lenvima, no included: activation or enrollment is required. • Patient’s information including Call your patient’s specialty full name pharmacy for details. • Date of service

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 47 TABLE OF CONTENTS Eisai

• Cost of the medication The card is solely intended to • CPT drug administration codes • Amount covered by the provide savings on any purchase • HCPCS Level II code insurance of the approved Eisai medica- • National drug codes • Patient’s responsibility: de- tion. Use of the card for any one • Revenue codes ductible; co-payment; and purchase does not obligate the • Medicare reimbursement rates co-insurance. patient to make future purchases • A checklist for claims of the same Eisai medication or submission. Step 4: If the patient’s claim is any other product. For patients approved, the appropriate funding prescribed Lenvima, this offer is Questions? Contact the Eisai based on the patient’s out-of-pocket available to MA residents through Assistance Program at 1.866.61. costs will be loaded onto the June 30, 2017, and to all other EISAI, Monday through Friday, patient’s card and a confirmation patients through March 31, 2020. 8:00 am to 8:00 pm EST. letter will be sent to you and your For patients prescribed Halaven, patient. this offer will expire November 20, 2019. Restrictions and Conditions REIMBURSEMENT Eligibility Criteria: Good toward ASSISTANCE the purchase of prescribed, eligible Eisai medication. No substitu- eisaireimbursement.com tions permitted. Save this card This program is your dedicated to reuse with each prescription. resource to help you answer Not available to patients enrolled your coverage questions. This in state or federal healthcare website eisaireimbursement.com programs, including Medicare, provides you with information Medicaid, Medigap, VA, DoD, or about payor-specific coverage TRICARE. May not be combined policies for the Eisai medication(s) with any other coupon, discount, you have prescribed, billing and prescription savings card, free coding requirements, and alterna- trial, or other offer. Federal law tive financial assistance options for prohibits the selling, purchasing, your patient. What to expect when trading, or counterfeiting of this you access eisaireimbursement.com: card. Such activities may result in • Product specific reimbursement imprisonment of 10 years, fines up information to $25,000, or both. Void outside • Understanding of coverage, the U.S. and where prohibited by coding and payment issues law. Eisai Inc. reserves the right to • Payer policy information. rescind, revoke, or amend this offer at any time without notice. Patients Eisaireimbursement.com offers and pharmacies are responsible providers a wide range of online for disclosing to insurance carriers tools for each of its products, the redemption and value of the including: card and complying with any other • Product information conditions imposed by insurance • Billing forms carriers or third-party payers. The • ICD-10-CM diagnosis codes value of this card is not contingent • ICD-10-CM Supplementary on any prior or future purchases. Classification Codes

48 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 49 TABLE OF CONTENTS EMD Serono, Inc. and Pfizer

EMD Serono, Inc. Pfizer Inc.

Oncology-related product: Bavencio® (avelumab) injection

Patient and Reimbursement Assistance Website coverone.com

PATIENT ASSISTANCE CoverOne Co-Pay assistance funds occurs after the Assistance Program patient has received treatment in an CoverOne™ Patient CoverOne provides co-pay assi- outpatient setting, and an Explana- Assistance Program stance for privately insured Bavencio® tion of Benefits (EOB) showing a CoverOne includes a patient (avelumab) injection 20 mg/mL separately payable Bavencio claim assistance program that provides patients with co-pay/co-insurance eligible for co-pay assistance is sent Bavencio at no charge for patients responsibilities who meet the to CoverOne. who meet certain income, insurance program eligibility criteria. (i.e., uninsured), and residency The patient co-pay assistance eligibility criteria. To determine Privately insured patients may apply program is not contingent on patient eligibility, patients and for assistance through the CoverOne any past or commercial sale of providers should complete and fax Co-pay Assistance Program by Bavencio. The co-pay program a CoverOne Enrollment Form and faxing a completed CoverOne does not assist with inpatient a prescription prior to treatment to Enrollment Form to 1.800.214.7295. hospital claims, or in any bundled 1.800.214.7295. Government-insured patients, payment arrangement where there including Medicare and Medicaid is no separate patient co-pay for Patient assistance is not applied beneficiaries, are not eligible for Bavencio, and does not assist with retroactively. A CoverOne the CoverOne Co-Pay Assistance healthcare premiums or drug representative will notify patients Program. Limits, terms, and administration services. and providers as soon as possible conditions apply. Full terms and with the patient’s eligibility conditions for co-pay assistance REIMBURSEMENT determination. can be found at CoverOne.com. ASSISTANCE

NOTE: The CoverOne patient CoverOne will notify patients and CoverOne assistance program is a philan- providers of the eligibility determi- Reimbursement thropic program for patients in nation as soon as possible. Enrolled Support Services need, and is not contingent on any patients will be responsible for a CoverOne™ will help providers and past or future commercial sale for $10 co-pay/co-insurance, and may patients understand the specific Bavencio. be eligible for Bavencio co-pay coverage and reimbursement guide- assistance up to a maximum of lines for Bavencio. Reimbursement $30,000 per year For enrolled support services include: patients, disbursement of co-pay

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 49 TABLE OF CONTENTS EMD Serono, Inc. and Pfizer

• Insurance Benefit Verification • Prior Authorization Assistance • Information on relevant billing codes for Bavencio • HCPCS, CPT, ICD-10-CM, NDC • Denied/Underpaid Claims Assistance • Payer Research (non-patient specific) • Medicare, Private Payers, State Medicaid • Alternate Funding Research

EMD Serono, Inc. and Pfizer, Inc. do not guarantee coverage and/or reimbursement for Bavencio. Coverage, coding, and reimburse- ment policies vary significantly by payer, patient, and setting of care. Actual coverage and reimburse- ment decisions are made by indi- vidual payers following the receipt of claims. Patients and healthcare professionals should always verify coverage, coding, and reimburse- ment guidelines on a payer and patient-specific basis.

Please fax a completed CoverOne Enrollment Form to 800-214-7295 to request services.

50 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 51 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), Tecentriq (atezolizumab injection), Venclexta™ (venetoclax tablets), Xeloda® (capecitabine), Zelboraf® (vemurafenib)

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

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 51 TABLE OF CONTENTS Genentech

Genentech BioOncology™ the patient met eligibility require- The BI can also determine if a prior Co-pay Card ments when the Genentech product authorization or patient assistance This Co-pay Card helps patients or service was received. Patients might be needed. To have Access with the out-of-pocket costs of do not need the physical card to Solutions conduct a BI, providers their prescription. Qualified receive benefits; they just need must request the assistance on the patients must: their ID code. If a patient is taking signed SMN form. There are three • Be covered by commercial more than one Genentech cancer possible outcomes of a BI: or private insurance medicine, these benefits apply to 1. Treatment is covered • Be receiving treatment each medicine individually. Need 2. Prior authorization is required that is consistent with the help with enrollment? Call 855. 3. Treatment is denied. FDA-approved use of the MYCOPAY (855.692.6729), Genentech therapy Monday through Friday, To begin with Access Solutions, • Not participate in a government 9:00 am-8:00 pm EST, or visit you must complete and submit the funded healthcare program, copayassistancenow.com. Statement of Medical Necessity such as Medicare, Medicaid, (SMN) form and have your patient Medigap, VA, DoD, or Referrals to Co-pay complete and submit a Patient TRICARE Assistance Foundations Authorization and Notice of • Be 18 years of age and older If patients need help with their Release of Information (PAN) • Currently live and receive medication co-pays, Access form. Login or download at treatment in the United States Solutions can connect them to genentech-access.com. Forms are or Puerto Rico co-pay assistance foundations drug-specific, so you must follow • There is no income requirement supporting their disease state. the prompts to access the correct for the Genentech BioOncology Genentech does not influence or forms. Patients can submit the Co-pay Card Program. control the operations of these PAN online at: pan.iassist.com/ co-pay assistance foundations, but forms/bioonc or download it online NOTE: Patients receiving funding Access Solutions can assist patients at: genentech-access.com. from the Genentech Access to by making an appropriate referral Care Foundation are not eligible to a foundation that may be able to Prior Authorization Assistance for the Genentech BioOncology help. Genentech cannot guarantee Access Solutions can help providers Co-pay Card Program. Some health co-pay assistance once a patient has identify whether a prior authoriza- plans might not accept a co-pay been referred by Access Solutions. tion (PA) is needed and help them card. Patients should contact their The foundations to which patients secure it. Simply complete and sign insurance providers to find out are referred will have their own a SMN form requesting assistance if their plan allows the use of criteria for patient eligibility, with the PA, as well as a signed and co-pay cards. including financial eligibility. dated PAN form (see instructions above). Access Solutions can help Under the Genentech BioOncology REIMBURSEMENT providers submit the required PA Co-pay Card Program, the patient ASSISTANCE forms and documentation. If the PA is responsible for a $25 co-pay is not granted, Access Solutions can per prescription or infusion. The Genentech work with providers to determine annual benefit limit of the co-pay Access Solutions next steps. card is $25,000. Retroactive Benefits Investigation requests for assistance from the Access Solutions conducts a benefits Appeals BioOncology Co-pay Card program investigation (BI) to help you better If providers have prescribed a may be honored if the infusion or understand your patient’s health Genentech product but an insurer prescription fill occurred within plan coverage for some or all of has denied coverage, they can 120 days prior to enrollment, and the costs associated with treatment. appeal that decision. Access

52 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 53 TABLE OF CONTENTS Genentech

Solutions might be able to help • Healthcare provider’s • User information including providers resolve the situation. chart notes email addresses (you may add Here is what you can do: • List of current medications, additional users at a later date) 1. Understand why the request with dose and frequency • Program or practice location or claim has been denied. This • List of treatments tried information (you may add addi- should be in the insurer’s letter without success tional locations at a later date) of denial or the patient’s Expla- • Test and lab results • Prescriber licensing information, nation of Benefits (EOB) letter. • Hospital admission/ including: a Prescriber National 2. Contact Access Solutions for emergency department Provider Identifier and State guidance as you put together notes. license number (required). an appeal. Use the resources 3 Other supporting documents, provided to help you gather the including journal articles, Providers will be asked to agree to documents and information you abstracts, textbook excerpts, the My Patient Solutions Practice need for a successful appeal. practice guidelines, and/or Agreement. They must agree to 3. Complete and submit the compendia indications. these terms to proceed with My required forms and documents Patient Solutions. For support, call to the insurer before the appeal My Patient Solutions™ 866.4ACCESS (866.422.2377), deadline. Access Solutions can My Patient Solutions allows you the 6:00 am to 5:00 pm PST, Monday provide information about flexibility to work with Genentech through Friday. Learn more at: this process. Access Solutions online whenever https://www.genentech-access.com/ you need. Features of My Patient hcp/learn-about-our-services.html. Here is a checklist of the forms and Solutions: documents you may need for an • Paperless enrollment: Enroll 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

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 53 TABLE OF CONTENTS Incyte Corporation

Incyte Corporation

Oncology-related products: Jakafi® (ruxolitinib) tablets

Patient and Reimbursement Assistance Website incytecares.com

PATIENT ASSISTANCE Jakafi as well as review infor- scription. The specialty pharmacy mation that is included in the will then contact the patient to IncyteCARES Patient Welcome Kit. make delivery arrangements. IncyteCARES (Connecting to • Connection to support services Access, Reimbursement, Education including referrals for transpor- IncyteCARES will determine and Support) provides a single tation assistance and access to whether patients qualify for point of contact through a regis- patient advocacy organizations additional services, such as tered nurse, OCN®, to assist eligible for counseling and emotional co-pay/coinsurance or free patients and healthcare providers support resources. product assistance. in obtaining access to Jakafi® To enroll your patient download (ruxolitinib) and to connect the enrollment form at: incyte Uninsured Patients them to continuing support and cares.com/pdf/jakafi-enrollment- Patients who do not have prescrip- resources. The program offers: form.pdf or call IncyteCARES at tion drug coverage for Jakafi may • Reimbursement support 1.855.4.Jakafi (1.855.452.5234). be eligible to receive the drug including insurance benefit free of charge through the verifications, information NOTE: Providers and patients IncyteCARES patient assistance about prior authorizations must work together to fill out program. This program helps and guidance with appealing the enrollment form. Completed people who do not have a prescrip- insurance denials or coverage forms should then be faxed to: tion drug plan, as well as those restrictions. 1.855.525.7207. In most states, whose plans have turned them • Access assistance including the enrollment form will serve as down for Jakafi treatment. Certain copay/coinsurance, free medi- the patient’s initial prescription conditions apply for prescription cation program & temporary for Jakafi. By signing the form, the savings. Patients may be eligible if access for insurance coverage patient is automatically enrolled they are a resident of the U.S. or delays for those that qualify in the Access, Reimbursement, Puerto Rico and their household and referrals to independent Education and Support services. size and annual income meet certain nonprofit organizations and If patients do not want these criteria, including earning less than foundations. services, they may opt out. Once $125,000 a year or less than 600% • Education and support including IncyteCARES receives the form, the of the Federal Poverty Level (FPL), access to a registered nurse, program will confirm the patient’s whichever is greater. Free product OCN®, who can provide prescription drug coverage and then is offered to eligible patients educational information coordinate with the appropriate without any purchase contingency about their condition and specialty pharmacy to fill the pre- or other obligation. In addition,

54 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 55 TABLE OF CONTENTS Incyte Corporation

patients insured through Medicare, 1.855.4.Jakafi (1.855.452.5234) influence or control them in Medicaid, TRICARE, and health- for full program terms and any way. care exchange plans are not eligible. eligibility. Terms of the program An IncyteCARES nurse can help are subject to change. REIMBURSEMENT determine if patients qualify for ASSISTANCE patient assistance. Visit Temporary Access IncyteCARES.com or call Eligible patients experiencing IncyteCARES coverage delays can receive a free A trained IncyteCARES nurse will 1.855.4.Jakafi (1.855.452.5234) for supply of Jakafi. Patients insured work with providers and patients more information and full eligibility through Medicare, Medicaid, to provide assistance with prescrip- criteria. Terms of the program are and TRICARE are not eligible. tion drug plan requirements that subject to change. Free product is offered to eligible must be met before patients can get patients without any purchase access to Jakafi. Some healthcare Co-pay/Coinsurance Assistance contingency or other obligation. plans may require prior authoriza- If patients are eligible, the To qualify, patients must submit tion, which means they will ask for co-pay/coinsurance assistance a proof of insurance claim more information from the provider program for Jakafi may be able to verifying delay. before deciding to pay for the reduce their co-payment to as little patient’s Jakafi. as $25 per month. Patients may Referral to an Independent be eligible for co-pay/coinsurance Nonprofit Organization IncyteCARES will work with assistance if they have commercial For patients who are not eligible for physicians to provide the necessary or private insurance, they are a assistance through IncyteCARES information to their patient’s resident of the U.S. or Puerto Rico, or who need additional support healthcare plan. In addition, if a they are 18 years of age or older, beyond what the program can healthcare plan will not pay for and they have a valid prescription provide, IncyteCARES can identify Jakafi, IncyteCARES can help for Jakafi for an FDA-approved and refer patients to other resources, providers and patients understand treatment. Uninsured, cash-paying such as independent nonprofit orga- what needs to be provided to patients are not eligible. Not nizations (INOs) or foundations. the healthcare plan to appeal the valid for patients covered under denial. While IncyteCARES cannot state or federally-funded health- INO's may be able to assist patients apply for the appeal, it can help care programs, such as Medicare, with arranging transportation to providers and patients determine Medicaid, or TRICARE. Patients and from medical appointments, the steps they may need to take must have minimum out-of-pocket travel cost assistance, copay/coin- to overturn the denial. If patients cost of $25.01 to redeem this card surance assistance and emotional experience insurance coverage and must contribute $25 towards and educational support. delays, IncyteCARES may be able that out-of-pocket cost. Patients to provide access to Jakafi. Eligible must disclose the use of the co-pay INOs may also be able to provide patients who have been prescribed card to their insurers. Amount of the following services to patients Jakafi for an FDA-approved savings of the purchase of Jakafi and caregivers: indication, and who are experienc- will not exceed $25,000 per year. • Supporting counseling for ing an insurance coverage delay Program benefits are subject to a emotional, social, and practical can receive a free supply of Jakafi monthly limit. Limit one 30-day concerns after proof of claims submission supply per 30 days. Card is valid • Information about support is provided. The free product is for one year after activation, after groups and referrals to local offered to eligible patients without which time a card must be reacti- services at no cost. Each of any purchase contingency or other vated to continue use. Visit these organizations has its own obligation. For more information, IncyteCARES.com or call set of rules, and Incyte does not contact IncyteCARES.

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 55 TABLE OF CONTENTS Ipsen

I psen Biopharmaceuticals, Inc.

Oncology-related products: Somatuline® Depot (lanreotide) Injection, Onivyde® (irinotecan liposome) Injection

Patient and Reimbursement Assistance Website ipsencares.com

PATIENT ASSISTANCE Program, or an independent no more than $5 per prescription. non-profit organization) with Program exhausts after 12 months, IPSEN CARES® free product for eligible patients 13 injections, or a maximum benefit The IPSEN CARES® (Coverage, under the IPSEN CARES of $20,000, whichever comes first. Access, Reimbursement & Education Patient Assistance Program Patients must enroll annually to Support) program provides free • Coordination of specialty receive a continued benefit. Cash medication to eligible patients pharmacy delivery paying patients may receive up through its Patient Assistance • Arrange for eligible patients to to $1,666.66 of support per pre- Program. IPSEN CARES will have a home health administra- scription, subject to the annual determine patient’s eligibility tion nurse visit their home to maximum of $20,000. The steps for for free product after the enroll- administer injections at no patients enrolled in IPSEN CARES ment process has been completed. additional cost to the patient to receive their Somatuline Depot Patients can call 866.435.5677, (for Somatuline® Depot) savings are: Monday through Friday, 8:00 am • Benefits verification and reim- 1. Electronic Medical Claims to 8:00 pm EST, to begin the enroll- bursement support. information is provided to the ment process. You can also enroll patient's provider. patients online at: https://ipsencare- Somatuline Depot 2. Provider inputs Electronic sportal.biologicsinc.com/Account/ Electronic Medical Medical Claim information Login or download the drug specific Claim Program into EMR system or onto the enrollment form (http://ipsencares. Patients who are enrolled in IPSEN CMS-1500 form and submits com/somatuline-patient-support) CARES and are beginning or claim to insurance company. and fax the signed and completed currently receiving treatment with 3. Provider receives payment form to 888.525.2416. IPSEN Somatuline Depot for an FDA- directly from their EMR vendor CARES offers the following services approved indication, who have via EFT or check, depending on for patients: commercial insurance that covers how their preferences are set. • Help minimize delays or inter- the medication and associated costs, 4. Patient's account is credited ruptions in treatment or are uninsured and paying their directly. • Provide financial assistance, entire out-of-pocket cost, may be including: copay assistance eligible for the Somatuline Depot (referring eligible patients to Electronic Medical Claim Program. Somatuline® Depot Copay Under this program, most eligible Program, Onivyde® Copay commercially insured patients pay

56 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 57 TABLE OF CONTENTS Ipsen

Onivyde Copay REIMBURSEMENT Assistance Program ASSISTANCE Patients who are enrolled into IPSEN CARES, formerly Provyde, IPSEN CARES receiving treatment with Onivyde IPSEN CARES offers the following that have commercial insurance Reimbursement Assistance services or are uninsured and paying cash to patients and providers: for their treatments are eligible • Benefits Verification: IPSEN for the Onivyde Copay Assistance CARES will help determine Program. The Onivyde Copay patient’s coverage, coverage Assistance program offers patients requirements, and co-payment up to $20,000 of annual support or co-insurance amount paying for their Onivyde treatment. • Prior Authorization: IPSEN Patients have a $0 out-of-pocket CARES will provide informa- responsibility until they reach the tion on documentation required $20,000 annual maximum. by payers, and make recommen- dations for next steps based on Patients will receive their treatment payer policy at their HCP office and have their • Appeals Support: IPSEN office submit the claim to the CARES will provide infor- insurance. The Explanation of mation on the payer specific Benefits (EOB) should be sent to process required to submit a IPSEN CARES for processing. Once level I or a level II appeal as processed, a check will be mailed well as provide guidance as to the HCP office on the patient's needed throughout the appeals behalf. process.

NOTE: This program is not Visit ipsencares.com for more available to individuals enrolled information. Questions? Call in federal or state subsidized 866.435.5677, Monday through healthcare programs that cover Friday, 8:00 am to 8:00 pm EST. prescription drugs, including Medicare (such as Medicare Part Patient Assistance D prescription drug benefit), Program Medicaid, TRICARE, or any other Ipsen is happy to provide free federal or state healthcare plan, product to eligible uninsured including pharmaceutical assis- patients who need Somatuline tance programs. This offer is only Depot or Onivyde. To qualify, available in the U.S. and Puerto patients must 1) have no insurance Rico, and is restricted in certain or be functionally uninsured, 2) be states. This offer may not be a US resident, 3) have an on-label combined with any other coupon, diagnosis, and 4) meet income discount, prescription savings card, criteria (% of FPL). free trial, or other offer.

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 57 TABLE OF CONTENTS Janssen

Janssen Biotech, Inc.

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

Patient and Reimbursement Assistance Website JanssenCarePath.com

PATIENT ASSISTANCE Affordability support treatment (not available for all to help patients start Janssen products) Janssen CarePath and stay on treatment • AdvocacyConnector.com. JanssenCarePath.com prescribed Janssen CarePath is your one source Janssen CarePath can help find Adherence tools for resources focused on access, affordability assistance that may be • Personalized reminders (not affordability, and treatment support available for patients taking Janssen available for all Janssen for your patients. medicines: products) • Support for patients using com- • Access to the Care4Today® Our Care Coordinator Team mercial or private insurance Connect App. supports all the Janssen medications • Support for patients using you prescribe. We can help make government insurance Call a dedicated Care it easier for you and your patients • Support for patients without Coordinator: to get the resources you both may insurance coverage. 877-CarePath (877.227.3728) need with a single, dedicated team Monday-Friday, supporting you and your patients Treatment support 8:oo am – 8:oo pm EST for all Janssen products. to help patients get Multilingual phone support informed and stay on available. Access support to prescribed treatment help patients start on Janssen CarePath helps keep Visit us online treatment prescribed patients informed about their JanssenCarePath.com by provider condition and the importance of Janssen CarePath helps verify staying on treatment with: Janssen CarePath insurance coverage for patients Savings Program and provides reimbursement Education tools information. • Patient education brochures Janssen CarePath Our offerings include: • Web-based resources Savings Program for • Benefits investigation support • Education about and referral ZYTIGA® • Prior authorization support to independent organizations The Janssen CarePath Savings • Triage to specialty pharmacy that provide assistance with Program may provide an instant providers, if needed. costs associated with travel savings on patient’s private or com- to and from mercial health insurance deductible,

58 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 59 TABLE OF CONTENTS Janssen

co-pay and coinsurance costs for beginning or currently receiving Janssen CarePath ZYTIGA®. If eligible, patients will treatment with DARZALEX® and Savings Program for pay no more than $10 per month, must have commercial insurance SYLVANT® up to a $12,000 maximum benefit that covers medication costs for The Janssen CarePath Savings or a one-year supply per calendar DARZALEX®. Eligible patients Program may provide a rebate for year. This program is not available must use commercial or private patients' out-of-pocket SYLVANT® to individuals who use any state health insurance that covers a costs. Patients may be eligible of federal government subsidized portion of their medication costs if they have been prescribed healthcare program to cover a for DARZALEX®. Patients using SYLVANT® and currently have portion of medication costs, such Medicare, Medicaid, or other commercial insurance that covers as Medicare, Medicaid, TRICARE, federally funded programs to pay medication costs for SYLVANT®. Department of Defense of Veterans for DARZALEX® medication are If eligible, patients may receive Administration. To learn more not eligible to participate. To learn a rebate for their out-of-pocket about the program, including more about the Janssen CarePath SYLVANT® medication expenses eligibility and restrictions, visit Savings Program, including full after they pay their full co-pay JanssenCarePath.com/Zytiga. eligibility requirements, visit amount to their healthcare provider JanssenCarePath.com/Darzalex. when they receive their treatment. Care Team members*, such as Patients will receive a rebate up Providers, Pharmacists, and Janssen CarePath to $1,000 per infusion for their Caregivers, can now utilize Savings Program for medication costs and pay $50 ZytigaCareTeam.com to activate a YONDELIS® per infusion. Costs of IV infusion Janssen CarePath Savings Program Eligible patients pay $20 for each services are not covered by this Card on behalf of an eligible patient infusion. Subject to a $15,000 program. The program exhausts receiving ZYTIGA®. maximum annual program benefit 12 months from the patient's first *Care Team members include the for each calendar year. Not valid eligible date of service. Patients patient’s Provider, Pharmacists, for patients enrolled in Medicare or may re-enroll annually to continue Caregivers, and/or other individuals Medicaid. Other restrictions may receiving a benefit from the who provide care for a patient and/ apply. Savings are determined by program. This program is not or have permission from the patient medication cost only, and not the available to individuals who use to assist with the activation of a cost associated with intravenous any state of federal government Janssen CarePath Savings Program infusion. For additional details, subsidized healthcare program Card. including complete eligibility to cover a portion of medication and restrictions, please visit costs, such as Medicare, Medicaid, Janssen CarePath JanssenCarePath.com/Yondelis. TRICARE, Department of Defense Savings Program for Patients may be eligible for the of Veterans Administration. For ad- DARZALEX® Janssen CarePath Savings Program ditional program details, including Eligible patients will pay no more for YONDELIS® benefits if eligibility and restrictions, or to than $10 per infusion and the beginning or currently receiving download the enrollment form, visit program can provide a rebate to treatment with YONDELIS® (tra- JanssenCarePath.com/Sylvant. patients for medication out-of- bectedin) and currently have com- pocket costs, including deductible, mercial or private health insurance co-payment, and coinsurance. For that covers a portion of medication infusions 1-8, patients pay $5 per costs for YONDELIS®. The costs of infusion. For infusions 9+, patients IV infusion services are not covered pay $10 per infusion. Maximum by this program. Other restrictions benefit per calendar year is up to may apply. $15,000. Eligible patients must be

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 59 TABLE OF CONTENTS Janssen

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

60 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 61 TABLE OF CONTENTS Lilly Oncology

Lilly Oncology

Oncology-related products: Alimta® (pemetrexed for injection), Cyramza® (ramucirumab), Erbitux® (cetuximab), Lartruvo™ (olaratumab), Portrazza™ (necitumumab)

Patient and Reimbursement Assistance Websites LillyPatientOne.com LillyCares.com

PATIENT ASSISTANCE • The date of service is within Insured Patients 120 days of the date of Even if your patient is fully insured, Lilly PatientOne submission a claim may still be denied. Lilly PatientOne (lillypatientone. Lilly PatientOne offers benefits com) provides a resource for If you have questions about patient investigation and appeals assistance access and reimbursement assis- eligibility requirements, PatientOne to qualified, insured patients. tance. Through Lilly PatientOne, program specialists are available If a patient’s claim is eligible, you may be able to help your Monday through Friday, 9:00 am to download and complete a qualified patients get the assistance 7:00 pm EST. Call 1.866.4PatOne Lilly PatientOne Application Form they need, allowing them to start (1.866.472.8663). at LillyPatientOne.com or call treatment with one less worry. 1.866.4PatOne (1.866.472.8663) Your patients may qualify for Lilly Cares Foundation to request a copy of the application the Lilly PatientOne program if The Lilly Cares Foundation, Inc., be sent to you. Fax the completed they meet eligibility requirements, a separate nonprofit organization, form to 1.877.366.0585. As you including: provides free Lilly medications fill out the form be sure to check • Patient is age 18 years or older to qualifying patients. For more all services that your patient • Patient must have proof of information about Lilly Cares, might need. The treating physician residency in the United States please visit LillyCares.com or call will receive a response from or Puerto Rico 1-800-545-6962. Lilly PatientOne once the patient’s • Patient must be treated with application has been reviewed. ALIMTA® (pemetrexed for If your patient has been prescribed PatientOne may: injection), CYRAMZA® a Lilly Oncology product and meets • Conduct a benefits investigation (ramucirumab), ERBITUX® the basic points of eligibility: to help verify coverage. (cetuximab), LARTRUVO™ 1. Download and complete Lilly • Provide prior authorization (olaratumab), or Portrazza™ Cares Application Form: requirements for the patient’s (necitumumab) for an LillyCares.com insurer. FDA-approved indication • Provide templates, forms, and • Patient must be commercially Learn more at: lillypatientone.com/ checklists for filing an appeal insured financial-assistance-for-cancer- for denied claims for eligible • Patient is ongoing therapy patients.html. Lilly Oncology products. (These

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 61 TABLE OF CONTENTS Lilly Oncology

forms can also be found online assistance program or another obtain financial and reimbursement in the “forms” section of the co-pay assistance program. assistance, including: Lilly PatientOne website). • Patients, pharmacists, and • Upon request provide status prescribers cannot seek Insurance Expertise updates for appeals that have reimbursement from health • Coding and billing information been filed for eligible Lilly insurance or any third party • Payment methodologies and Oncology products. for any part of the benefit allowables received by the patient through • Payer policy information. Lilly PatientOne this offer. Co-Pay Program Reimbursement Assistance With the Lilly PatientOne Co-pay Patient Enrollment Steps: • Eligibility determination Program for Alimta, Cyramza, 1. Download an application form: • Benefits investigation Erbitux, Lartruvo, or Portrazza, lillypatientone.com/assets/pdf/ • Prior authorization eligible patients can lower co-pay patient_assistance_program_ • Evaluation other funding or coinsurance costs to pay no application.pdf or call Lilly options. more than $25 per dose. Eligibility PatientOne at 1.866.4PatOne criteria: (1.866.472.8663) for a faxed Denied Claim Appeals • Patient is age 18 years or older copy. • Appeals status if requested • Patient must have proof of 2. Review program eligibility with • Denied claims appeals residency in the United States your patient based upon the full templates, forms, and checklists. or Puerto Rico criteria listed in the application. • Patient must be treated with 3. Fax the completed application Lilly PatientOne program specialists ALIMTA® (pemetrexed for to 1.877.366.0585. are available Monday through injection), CYRAMZA® 4. Your patient’s application will Friday, 9:00 am to 7:00 pm (ramucirumab), ERBITUX® be reviewed to determine eligi- EST. Call 1.866.4PatOne (cetuximab), LARTRUVO™ bility pursuant to business rules. (1.866.472.8663). Learn more (olaratumab), or Portrazza™ 5. Approved patients will receive at: lillypatientone.com. (necitumumab) for an an enrollment letter and their FDA-approved indication co-pay card in the mail. • Patient must be commercially 6. Your office will be informed insured of patient’s enrollment status • Patient is ongoing therapy through a faxed letter. (NOTE: • The date of service is within remind patients to bring their 120 days of the date of co-pay card with them to their application submission next appointment.) • Maximum patient benefit $25,000 per 12-month period Questions? Call 1.866.4PatOne (1.866.472.8663). Non-eligible: • Participants in Medicaid, REIMBURSEMENT Medicare, Medicare Part D, ASSISTANCE Medigap, CHAMPUS, DoD, VA, TRICARE, or any state Lilly PatientOne patient or pharmaceutical Reimbursement assistance program Services • Patients currently eligible for, PatientOne offers resources that or enrolled in, a Lilly patient may help your qualified patients

62 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 63 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, SylatronTM (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 • Answer questions about filling mine) for Injection 150 mg out the enrollment form. • Intron A (interferon alfa-2b, Merck Access Program recombinant) for Injection, The Merck Access Program Contact the Merck Access Program 10 million IU, 18 million IU, (merckaccessprogram.com) can at 855.257.3932, Monday through 50 million IU help answer questions about access Friday, 8:00 am to 8:00 pm EST. • Keytruda (pembrolizumab) and support, including: Or download the enrollment form Injection [liquid formulation] • Insurance coverage for patients at: merckaccessprogram.com/static/ 100 mg • Reimbursement pdf/ONCO-1143560-0002.pdf and • Sylatron (peginterferon alfa-2b) • Co-pay assistance for eligible fax it to: 855.755.0518. for injection, for subcutaneous patients use, 200 mcg, 300 mcg, 600 • Benefit investigations, prior The Merck Patient mcg authorizations, and appeals Assistance Program • Temodar (temozolomide) • Referrals to the Merck Patient This program (merckhelps.com) Capsules 5 mg, 20 mg, 100 mg, Assistance Program. provides certain Merck medicines 140 mg, 180 mg, 250 mg and vaccines free of charge to • Zolinza (vorinostat) 100 mg A dedicated representative of the eligible individuals, primarily the Capsules. Merck Access Program may be uninsured, who without assistance able to: could not afford these needed The Merck Patient Assistance • Research your patient’s Merck medicines. The Merck Program offers temporary assis- insurance benefits Access Program was designed to tance to patients who generally • Obtain information on your help patients who have been pre- meet the following requirements: patient’s out-of-pocket costs scribed any of the following Merck 1. They are a U.S. resident and • Provide information on co-pay medicines: physician/prescriber has deter- assistance options • Emend (aprepitant) 80 mg, mined that a Merck product • Refer patients to the Merck 125 mg capsules may be appropriate for treating Patient Assistance Program • Emend (fosaprepitant dimeglu- the patient

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 63 TABLE OF CONTENTS Merck

2. They have no pharmaceutical • Meet financial eligibility criteria Vaccine Patient insurance coverage (to view the criteria visit: Assistance Program 3. They meet specified financial merckaccessprogram-keytruda. Patients who want to receive the criteria and cannot afford to com/hcp/the-merck-copay- Gardasil vaccine may be eligible pay for their medicine. assistance-program/ and for the program if all three of the select the link for “Terms and following conditions apply: NOTE: Individuals who do not Conditions”) • Patients reside in the U.S. and meet the insurance criteria may • Meet all other terms and are 19 to 26 years of age. still qualify for the Merck Patient conditions as outlined on the (NOTE: Patients do not have to Assistance Program if they attest Keytruda co-pay assistance be U.S. citizens. Legal residents that they have special circumstances website. of the U.S. and U.S. territories of financial and medical hardship, Once enrolled, eligible, privately are also eligible to apply.) and their income meets the program insured patients pay the first • Patients have no health criteria. $25 of their co-pay per infusion. insurance coverage. (Some The maximum benefit under this examples of health insurance To enroll in the Merck Patient program is $25,000 per patient per coverage include private Assistance program, visit calendar year (based on income). insurance, HMOs, PPOs, merckhelps.com. This site will college health plans, Medicaid, refer you to the Merck Access site Download the Merck enrollment veterans’ assistance, or any for the specific medication you are form at: merckaccessprogram- other social service agency prescribing, and it is where patients keytruda.com/static/pdf/merck- support.) can begin the enrollment process, access-program-keytruda- • Patients have an annual using the prescription specific enrollment-form.pdf and fax it to: household income less than: enrollment form. Questions 855.755.0518 or enroll online at: - $47,520 or less for about the Merck Patient Assistance merckaccessprogram-keytruda. individuals Program? Call 1.800.727.5400, com/hcp/merck-access-program-key - $64,080 or less for couples Monday through Friday, 8:00 am truda-enrollment-form/. - $97,200 or less for a family to 8:00 pm EST. of 4. NOTE: Co-pay assistance from the For income limits in Alaska Co-Pay Assistance for Merck Co-pay Assistance Program and Hawaii, please call 1.800. Keytruda is not insurance. Visit the Merck 727.5400. The Merck Co-Pay Assistance Co-pay Assistance Program website Program offers assistance to eligible (link above) for restrictions, terms, NOTE: Individuals who do not patients who need help affording and conditions. If your patient is meet the insurance coverage criteria Keytruda. Co-pay assistance may be deemed ineligible for the Merck may still qualify for the vaccine available for patients who: Co-pay Assistance Program for program if the patient has special • Are at least 18 years of age Keytruda, a representative can circumstances of financial and • Are a resident of the U.S. provide you with information about medical hardship, and their income (including Puerto Rico) independent foundations that may meets the program criteria. • Have private health insurance be able to provide your patient with that covers Keytruda under a financial support. Each independent medical benefit program foundation has its own eligibility • Have been prescribed Keytruda criteria and application process. for an FDA-approved indication

64 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 65 TABLE OF CONTENTS Merck

Enrollment is Easy 2. Fax the completed form to: 3. A new application will need to 1. Complete and sign the applica- 1.800.528.2551 from a par- be completed and submitted tion form. It is available online ticipating licensed provider’s to the Merck Vaccine Patient at: merckhelps.com/docs/VPAP_ office. The application must be Assistance Program for eligibil- Enrollment_Form_English.pdf submitted and approved prior ity assessment prior to a patient (English) and merckhelps.com/ to administration of vaccine receiving a subsequent dose in a docs/VPAP_Enrollment_Form_ in order to qualify. Forms will multidose series or for another Spanish.pdf (Spanish). Providers be processed quickly—with a Merck vaccine. and their office personnel can goal of less than 10 minutes also call 1.800.293.3881, (between business hours of 8:00 Monday through Friday, 8:00 am-8:00 pm, EST, Monday am-8:00 pm EST, to obtain through Friday)—and the enrollment applications for provider’s office will be notified patients and to request addi- by phone so that qualifying tional information about the patients can receive the Merck program. vaccine during that visit.

2016-2017 Federal Poverty Guidelines

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

1 $11,880 $15,800 $16,394 $29,700 $47,520

2 $16,020 $21,300 $22,108 $40,050 $64,080

3 $20,160 $26,800 $27,821 $50,400 $80,640

4 $24,300 $32,300 $33,534 $60,750 $97,200

5 $28,440 $37,850 $39,247 $71,100 $113,760

6 $32,580 $43,350 $44,960 $81,450 $130,320

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

8 $40,890 $54,400 $56,428 $102,225 $163,560

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 65 TABLE OF CONTENTS Novartis

Novartis Pharmaceuticals Corporation

Oncology-related products: Afinitor® (everolimus) tablets, Arzerra® (ofatumumab) injection, 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, Rydapt® (midostaurin) capsules, Sandostatin® (octreotide acetate) for injection, Sandostatin LAR® Depot (octreotide acetate for in- jectable suspension), Tafinlar (dabrafenib) capsules, Tasigna® (nilotinib) tablets, Tykerb® (lapatinib) tablets, Votrient® (pazopanib) tablets, and Zykadia™ (ceritinib) capsules

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

PATIENT ASSISTANCE • Not have private or public prescribed Exjade [deferasirox] prescription coverage. (NOTE: tablets to your patient, call The Novartis Patient Exception process exists.) the EPASS Prescription and Assistance Foundation Reimbursement Hotline at This foundation (patientassistance Patients must reapply and re-qualify 1.888.903.7277.) now.com/info/programsto every 12 months. Questions? accessmedicines/patientassistance Contact the Novartis Patient Novartis Oncology information.jsp) provides assistance Assistance Foundation at: Universal Co-Pay Card to patients experiencing financial 1.800.277.2254, or go online to: Novartis Oncology created its hardship who have no third- patientassistancenow.com. Universal Co-Pay Program (copay. party insurance coverage for their novartisoncology.com) to help with medicines. To be eligible for the There are three ways to enroll in prescription costs for all the medi- Novartis Patient Assistance Fund, the program: cations listed below: patients must: • Enroll online by visiting: • Afinitor • Be a U.S. resident. pharma.us.novartis.com/info/ • Exjade • Meet income criteria, which patient-assistance/patient- • Farydak vary by medication, and provide assistance-enrollment.jsp, • Femara proof of income. Financial eligi- and selecting the appropriate • Gleevec bility program requirements are Novartis medication from the • Jadenu 250% to 500% of the Federal drop down menu, and following • Mekinist Poverty Level, depending on the the instructions • Odomzo Novartis medicine. • Call 1.800.277.2254 to enroll • Promacta by phone. (Note: If you have • Rydapt • Sandostatin LAR Depot

66 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 67 TABLE OF CONTENTS Novartis

• Tafinlar Authorization and the Patient 1.800.282.7630, Monday through • Tasigna Assistance Program (PAP) Friday, 9:00 am to 8:00 pm EST. • Tykerb Consent for Patient (if applica- • Votrient ble). For Zykadia and Farydak REIMBURSEMENT • Zykadia. specialty pharmacy submission ASSISTANCE only, patient signature is not It’s simple to use and easy to find mandatory. Patient Assistance out if patients are eligible for the • Insurance Information (Section NOW Oncology program. Eligible patients may 2). Please include a copy of the (PANO) pay no more than $25, subject to front and back of the patient’s PANO (oncologyaccessnow.com) a maximum benefit of $15,000 insurance card(s). helps patients and healthcare per calendar year. Find out if this • Patient Financial Information providers with questions about program is right for your patient by (Section 3). This section only insurance verification and other calling 1.877.577.7756 or by going needs to be completed if you reimbursement issues including, to: copay.novartisoncology.com and believe the patient could be • Benefits investigations clicking on the name of the medica- eligible for the Patient Assistance • Prior authorizations tion. This offer is not valid under Program (PAP). For patient • Assistance with denials and Medicare, Medicaid, or any other assistance consideration, please appeals. federal or state program. Novartis attach proof of income, i.e., reserves the right to rescind, revoke, wage stubs, employer statement Providers can download and or amend this program without of income, tax returns, etc. complete the Novartis Service notice. Limitations apply. Read • Physician Information (Section Request Form at: hcp.novartis.com/ program terms and conditions at: 4). Complete with all relevant globalassets/approved_onc-11121 copay.novartisoncology.com. information and best contact 63-novartis-universal-enrollment- person. Be sure to sign the form-gsk-update-digital1.pdf and, Patient Assistance Physician Authorization and following the directions above, NOW Oncology Patient Assistance Program fax it to: 1.888.891.4924 (NOTE: (PANO) (PAP) Consent for Physician follow instructions on enrollment PANO (oncologyaccessnow.com) (if applicable). form for enrolling patients on offers quick and easy access to in- • Pharmacy Preference (Section Zykadia and Farydak through a formation about the wide range of 5). Choose your patient’s specialty pharmacy.) Questions? resources available to your patients. preferred pharmacy (if Call 1.800.282.7630. Enroll your patients into Novartis applicable). Oncology support programs by • Prescription Information Oncology completing this form: hcp.novartis. (Section 6). Please complete the Reimbursement com/globalassets/approved_ selected prescription informa- Hotline onc-1112163-novartis-universal- tion for your patient. Ensure By calling 1.800.282.7630, enrollment-form-gsk-update- that all necessary prescriber providers and patients can receive digital1.pdf. signatures are included. assistance in resolving reim- bursement issues and concerns, Follow the steps below to complete Fax completed forms to: including: the Novartis Service Request Form: 1.888.891.4924. (NOTE: follow • Insurance verification. Program • Patient Information (Section instructions on enrollment form staff verify patients’ medical 1). Complete with all relevant for enrolling patients on Zykadia benefits, helps determine information. Be sure to have and Farydak through a specialty insurance coverage, and clarify the patient sign the Patient pharmacy.) Questions? Call co-payment obligations.

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 67 TABLE OF CONTENTS Novartis

• Denials and appeals. Program staff can assist you and your Active Listening 101 patient with the appeals process. Active listening is a communication technique that requires the listener • Referrals to co-pay cards. to feed back what is heard to the speaker by re-stating or paraphrasing • Alternative funding searches. what was heard in the listener’s own words. Active listening improves Program staff can search for personal relationships, reduces misunderstanding and conflicts, strengthens possible assistance for patients cooperation, and fosters understanding. The skill is proactive, accountable, with insufficient medical benefit and professional. coverage or no drug coverage and refer to other sources of Active listening is comprised of three primary elements: comprehension, funding that could help alleviate retention, and response. or reduce costs. • Referrals to patient assistance Comprehension—develop a shared meaning between parties through tone for low-income uninsured of voice, use of vocabulary and context, and speech pattern. patients. Retention—take notes if necessary. • Help finding pharmacies Response—respond both verbally and non-verbally. that stock Novartis medica- tion. Program staff can also overnight an emergency supply, Active Listening Tactics and find other ways to get your • Listen and hear rather than waiting to speak. patient their Novartis medicine. • Watch body language. The Reimbursement Hotline and • Find common ground. Novartis Pharmaceuticals Corpora- • Paraphrase the speaker’s words back to him or her as a question. tion do not guarantee success in (“I see/hear/feel like you are afraid of…”) obtaining reimbursement, nor do • Suspend your own frame of reference and judgments. they submit appeals on behalf of providers or patients. Third-party • Validate what the speaker is saying and feeling (“You seem to feel angry, payment for medical products and is that because…?”) services is affected by numerous factors, not all of which can be Barriers to Active Listening anticipated or resolved by Reim- • Distractions bursement Hotline staff. • Trigger words • Vocabulary • Limited attention span • Emotions • Noise and visual distraction • Cultural differences • Interrupting or influencing

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

68 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 69 TABLE OF CONTENTS Pfizer

Pfizer, Inc.

Oncology-related products: Aromasin® (exemestane tablets), Bavencio® (avelumab) Injection (co-marketed with EMD Serono, Inc.), 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, Sutent® (sunitinib malate), Torisel® (temsirolimus) injection, Xalkori® (crizotinib) capsules, Zinecard® (dexrazoxane for injection)

Patient and Reimbursement Assistance Website pfizerrxpathways.com

PATIENT ASSISTANCE patients with Medicare/ their prescription medicines. Now, Medicare Part D, Medicaid, to answer patients’ changing needs Pfizer Oncology and other government insurance and make our services more acces- Together plans sible, we’ve combined our existing At Pfizer Oncology Together, we’re • Uninsured patients without any programs into one program called committed to working alongside form of healthcare coverage Pfizer RxPathways. Formerly Pfizer healthcare professionals so that Helpful Answers, Pfizer RxPathways no patient goes without the Pfizer We also offer personalized in-office is a comprehensive assistance pro- Oncology medication you’ve support to help office staff navigate gram that provides eligible patients prescribed—regardless of their access and reimbursement issues. with a range of support services, insurance coverage. Resources supporting this initiative including insurance counseling, are in development. Please reach co-pay assistance, and access to We offer access and reimburse- out to your Pfizer Representative medicines for free or at a savings. ment services to overcome barriers for additional details. and we have a range of offerings • For live personalized support, Pfizer Savings Card to provide patients with financial call 1.877.744.5675 Monday to This card will provide patients with support. Friday, 8:00 AM to 8:00 PM ET a 50 percent savings off the cost • To get started, fax completed of their Pfizer Oncology medicine. We’ll work with your patients to enrollment form to You may call Pfizer patient support help find the right financial support, 1.877.736.6506 at 1.877.744.5675 for assistance regardless of insurance coverage. • To learn more, visit on how to obtain this savings card. There’s assistance for: PfizerOncologyTogether.com Certain eligibility criteria • Commercially insured patients are required. with commercial, private, Pfizer RxPathways employer, and state health For more than 25 years, Pfizer has Services for Uninsured Patients insurance marketplace coverage offered a number of assistance pro- Uninsured patients may be able • Medicare/Government insured grams to help eligible patients access to get certain specialty medicines

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 69 TABLE OF CONTENTS Pfizer

for free if they cannot secure tance programs, Medicaid, Medicare • Live in the United States, Puerto insurance coverage. To apply Part D, and low-income subsidies). Rico, or the U.S. Virgin Islands. for free medicine, patients and During this time, eligible patients • Be treated as an outpatient. their prescribers must download will be given up to a 90-day supply and complete the Group B ap- of free medicine. If eligible patients To apply for free medicine, plication at: http://www.pfizer- cannot secure insurance coverage, patients and their prescribers must rxpathways.com/sites/default/files/ they will continue to get free download and complete the Group attachment/0401%20RxPathway- medicine through Pfizer RxPath- B application (http://www.pfizer- sGroupB_081816.pdf. The applica- ways for up to 12 months. rxpathways.com/sites/default/files/ tion, along with any other required attachment/0401%20RxPathway- documents should be faxed to: Within two business days, patients sGroupB_081816.pdf) and mail or 800.708.3430 or mailed to: Pfizer will be notified of their enrollment fax it (see address and fax number RxPathways, P.O. Box 66976, St. status over the phone. If accepted, above) to Pfizer RxPathways along Louis, MO 63166-6976. patients will then receive a letter with any other required documents. containing their enrollment term If patients require immediate assis- If patients require immediate assis- and next steps on how to receive tance with their specialty medicines, tance with their specialty medicines, their free specialty medicine(s). For they or their prescribers should call they or their prescribers should call more information on the eligibil- 1.877.744.5675, Monday through 1.877.744.5675, Monday through ity requirements, application, and Friday, from 8:00 am to 8:00 pm Friday, 8:00 am to 8:00 pm EST enrollment process, see the Group EST to start the process. B application: http://www.pfizer- To be eligible for free specialty rxpathways.com/sites/default/files/ After applying to or contacting medicines, uninsured patients must: attachment/0401%20RxPathway- Pfizer RxPathways, a Pfizer • Be prescribed a Pfizer specialty, sGroupB_081816.pdf. RxPathways counselor will first or “Group B,” medicine. To work with underinsured patients view these medicines, click Services for Underinsured to find and apply for other ways “View Group B Medicine List” Patients to help patients with their co-pay. on the Pfizer RxPathways If patients have prescription Other sources of help could come website (http://pfizerrxpath- coverage, but still cannot afford from co-pay foundations, Medicare ways.com/en/see-how-we-help). their Pfizer specialty medicines, Part D, low-income subsidies, and • Have no prescription coverage they may be able to get them for even co-pay card programs. If other to pay for their Pfizer medicines. free. To be eligible for free specialty funding cannot be secured, patients • Meet certain income limits that medicines, patients without enough may be eligible to receive their vary by medicine and household health insurance coverage must: Pfizer specialty medicines for free size. • Be prescribed a Pfizer specialty, through Pfizer RxPathways. • Live in the United States, Puerto or “Group B,” medicine. To Rico, or the U.S. Virgin Islands. view these medicines, click Within two business days, patients • Be treated as an outpatient. “View Group B Medicine List” will be notified of their enroll- on the Pfizer RxPathways ment status. If accepted, they will After applying or contacting website (http://pfizerrxpath receive a letter that contains their Pfizer RxPathways, a Pfizer ways.com/en/see-how-we-help). enrollment term and next steps on RxPathways counselor will first • Have prescription coverage, how to receive their free specialty work with uninsured patients but not enough to pay for their medicine(s). Medicines will to find and apply for insurance Pfizer medicines. typically be shipped to a patient’s options that may help them access • Meet certain income limits home, or to a prescriber’s office. their Pfizer specialty medicines that vary by medicine and (e.g., state pharmaceutical assis- household size.

70 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 71 TABLE OF CONTENTS Pfizer

In some cases, patients who apply • Patients may receive up to • They do not purchase pre- for free medicine and have private $25,000 in savings annually. scriptions through Medicare, insurance coverage may instead Limits, terms and condi- Medicaid, or a federal or receive co-pay assistance through tions apply. This offer is only state program Pfizer RxPathways. Instead of available at participating • They are not a resident of a having free medicine shipped to pharmacies. This offer is not state where this program is them, these patients will receive health insurance. No member- prohibited by law. (Please check a Pfizer RxPathways co-pay card ship fees. To register and see the your brand’s website for specific to use at their local pharmacy full terms and conditions, go terms and conditions.) to cover the entire cost of their to: www.PfizerCoPayOne.com/ co-pay. (NOTE: Pfizer RxPath- pharmacist. To verify eligibility, select ways Co-Pay Assistance is not brand-name product from those health insurance. For a complete My Pfizer Brands listed in the keyboard located on list of participating pharmacies My Pfizer Brands is a program that the My Pfizer Brands home page call 1.877.744.5675.) For more helps patients receive prescription (mypfizerbrands.com) then click information on the eligibility savings on the Pfizer medications through to the available savings requirements, application, and they have been prescribed. Many offer. If patients are not eligible, enrollment process, see the Group people, even those with prescrip- there may be other ways they can B application (http://www.pfizer- tion coverage, may save with this save on their prescriptions through rxpathways.com/sites/default/files/ program. Terms and conditions Pfizer RxPathways, Pfizer’s patient attachment/0401%20RxPathway- apply. If the product is available assistance program. Learn more at: sGroupB_081816.pdf). Patients as a generic, patients may pay less PfizerRxPathways.com. who participate in any federal or with other offers or by receiving state programs, such as Medicaid the generic. See full terms and REIMBURSEMENT or Medicare, are not eligible for conditions on each respective Pfizer ASSISTANCE co-pay assistance. However, these brand medication website. The card patients may be eligible to receive will be accepted only at participat- Insurance Counseling their medicine for free through ing pharmacies. The card is not If insured or underinsured patients Pfizer RxPathways. Terms and health insurance. No membership need help understanding their conditions apply. fees. Maximum annual savings coverage and reimbursement of $400 to $10,000. For more options for certain Pfizer specialty Pfizer Co-Pay One Card information, call 1.866.341.9100 medicines, Pfizer RxPathways can Commercially insured (commercial, or write to Pfizer, PO Box 29387, help by offering: private, employer and healthcare Mission, KS 66201-9618. • Reimbursement support. A exchange patients) patients qualify Pfizer RxPathways counselor- for co-pay One’s offer – maximum Regardless of income or employ- will research and verify benefits, of $10 out of pocket. ment status, patients may qualify outline coverage options • The Pfizer Co-Pay One card for the My Pfizer Brands program if: and policies, and explain the enables patients with com- • They pay for prescriptions with prior authorization process to mercial, private, employer and insurance at the pharmacy (this patients and their prescribers. Healthcare exchange insurance means they are self-insured • Appeals process information. to fill their prescription with a or have prescription coverage If a claim is underpaid or maximum out of pocket cost through their employer or their denied, Pfizer RxPathways of $10. spouse’s employer) will investigate it and provide • Patients must live in the US or • They pay out-of-pocket patients with information on Puerto Rico and be 18 years of (cash) for their prescriptions the appeals process. age or older to qualify. at the pharmacy

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 71 TABLE OF CONTENTS Pfizer

• Specialty pharmacy referral. from either your desktop or • Pfizer samples. Eligible health- For patients prescribed Bosulif, tablet device. care professionals can sign in Ibrance, Inlyta, Sutent, or Xalkori • Grants and fellowships. or register for PfizerPro, choose (crizotinib), Pfizer RxPathways Pfizer seeks to cooperate with from eligible samples or savings will refer them to a retail or healthcare delivery organiza- cards, and submit their requests. specialty pharmacy that will tions and professional associa- PfizerPro members can also call verify their benefits and help to tions to narrow professional 1.888.736.8220 for more infor- fill their prescriptions. practice gaps in areas of mutual mation and to request samples. interests through support of (NOTE: Not all Pfizer products To receive insurance counseling for learning and change strate- are available for sampling certain specialty medicines, patients gies that result in measurable through this program.) can call 1.877.744.5675, Monday improvement in competence, • Vaccine ordering. Pfizer is through Friday, 8:00 am to 8:00 pm performance, or patient committed to the prevention EST. Patients can also download outcomes. of life-threatening diseases. and submit the Group B applica- • Hispanic/Latino learning series For over a century, Pfizer and tion to begin the process. For are PowerPoint presentations its legacy companies have more information on the eligibil- designed to educate healthcare played a critical role in techno- ity requirements, application, and professionals and other key logical developments against enrollment process, see the Group stakeholders on cultural com- diseases such as pneumococcal B application: http://www.pfizer- petency for Hispanic/Latino pneumonia. This is where you rxpathways.com/sites/default/files/ populations. can order vaccines for your attachment/0401%20RxPathway- • Pfizer medical information. practice. sGroupB_081816.pdf. Have a medical question? Submit a medical question, chat Pfizerpro.com live about Pfizer prescription PfizerPro (pfizerpro.com) offers medicines, and more. physicians the support they need to • Pfizer patient-reported help improve their practice and outcomes is a resource for the lives of their patients, including: up-to-date versions and trans- • Clinical trial listings. Search the lations of many available database of ClinicalTrials.gov measures used to assess for available clinical trials by patient-reported outcomes. It keyword, trial phase, location, offers current information on and more. validated measures developed • Digital product presenta- by Pfizer in various therapeutic tions. These self-guided, online areas, including CV/metabolic, learning sessions are available neuroscience, oncology, pain, for certain Pfizer products and sexual health, urology, and are designed to leave providers women’s health. with a clearer understanding • Pfizer Responsible Disposal of the Pfizer product discussed. Advisor assists institutional The presentations feature case facilities in properly disposing studies, mechanism of action of unused medicine. The site videos, efficacy and safety infor- is now available to healthcare mation, and more, all of which facilities and providers. Answers can be viewed at your own pace to your product disposal questions are only a click away.

72 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 73 TABLE OF CONTENTS Pharmacyclics

Pharmacyclics, LLC

Oncology-related products: Imbruvica™ (ibrutinib)

Patient and Reimbursement Assistance Website imbruvica.com/youandi

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

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 73 TABLE OF CONTENTS Sandoz

Sandoz, Inc.

Oncology-related product: ZarxioTM (filgrastim-sndz)

Patient and Reimbursement Assistance Website sandozonesource.com

PATIENT ASSISTANCE assistance, enrollment in the Sandoz Section 7: Commercial co-pay One Source Co-pay Program, program. Skip this section if Sandoz One Source™ and/or information on external applying for the patient assistance Sandoz One Source is a compre- resources, complete sections 1-7: program. hensive program designed to help simplify and support patient access Section 1: Patient information Section 8: Patient consent/ for those prescribed Zarxio. Sandoz signature & financial informa- One Source offers a variety of Section 2: Insurance information. tion. Complete only if you believe customized services for patients, Include policy information for the patient could be eligible for including: both your patient’s primary and patient assistance. For patient as- • Comprehensive insurance secondary insurance (as applicable). sistance consideration, patients may verifications It helps to include a copy of the sign consent for real-time income • Prior authorization support, front and back of the patient’s projector or may opt to include when required by the insurance insurance card(s). If your patient proof of income documentation. company has no insurance, check the “No The enrollment form is also • Billing and coding information Insurance” box. available online via the Sandoz One • Claims tracking information Source Provider Portal. To access • Denials/Appeals information Section 3: Treatment & prescrib- the Provider Portal visit: sandozon • General payer policy research. ing information. Primary and esource.com. Questions? Call secondary ICD/Dx are required. 844.SANDOZ1 (844.726.3691), Sandoz One Source is available to Remember to enter drug name in 9:00 am to 8:00 pm EST, Monday assist patients with: the first row of this section. through Friday. • Information on external resources and support Section 4: Prescriber informa- Sandoz One Source • Sandoz One Source Commercial tion. Include office/primary contact Co-Pay Program Co-Pay Program eligibility. person. The Sandoz One Source Co-pay Program is available for all eligible, Download an enrollment form for Section 5: Patient authorization & commercially insured patients who patient assistance at: sandozone signature. have been prescribed Zarxio. There source.com. For patient assistance is no income eligibility require- program, complete Sections 1-6, Section 6: Prescriber authorization. ment for this program. Under this and Section 8. For reimbursement program, patients pay $0 for their

74 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 75 TABLE OF CONTENTS Sandoz

first dose or cycle, and are responsi- REIMBURSEMENT ble for a $10 out-of-pocket cost for ASSISTANCE subsequent doses or cycles, subject Sandoz One Source offers a variety to a maximum benefit of $10,000 of reimbursement assistance annually. services for patients and providers. For reimbursement assistance, The Sandoz One Source Co-pay complete the Sandoz One Source Program is not insurance. It is enrollment form, Sections 1-7, available only to patients with found at: www.sandozonesource. commercial insurance. Cash-paying com. Reimbursement services patients, uninsured patients, and include: patients with federal or state- • Comprehensive insurance funded insurance are not eligible verifications for this program. The program • Prior authorization support, not available in states where it is when required by the insurance prohibited by law. Patients must company be prescribed Zarxio for an FDA- • Billing and coding information approved indication. Patients can • Claims tracking information participate in the program for • Denials/Appeals information up to 12 months or until age 65, • General payer policy research. whichever comes first. Other terms and conditions apply. You can download the enroll- ment form, or enroll your patients To enroll in the Sandoz One Source online via the Sandoz One Source Co-pay Program patients must Provider Portal. Questions? Call complete the Sandoz One Source 844.SANDOZ1 (844.726.3691), enrollment form described above. 9:00 am to 8:00 pm EST, Monday Patients should complete Sections through Friday. 1-7 of the form. To enroll, or to learn more about the program restrictions and eligibility require- ments visit: www.sandozonesource. com, or call: 844.SANDOZ1 (844.726.3691), 9:00 am to 8:00 pm EST, Monday through Friday.

ACCC 2017 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 seagensecure.com

PATIENT ASSISTANCE important that each field is filled NOTE: To be eligible for the out completely and accurately to Co-Insurance Assistance Program, SeaGen Secure™ ensure timely processing of the ap- patients must have coverage for Patient Assistance plication. If you have any questions, Adcetris through a commercial Program please call 855.4SEAGEN insurer, be at least 18 years old, and SeaGen Secure offers an Adcetris (855.473.2436), option 1, to speak be seeking treatment for a labeled Co-insurance Assistance Program with a reimbursement counselor. indication. for uninsured and underinsured patients who have been prescribed Benefits Investigation If patient does not have coverage Adcetris. Once an enrollment form Once the enrollment form is re- for Adcetris: (https://seagensecure.com/assets/ ceived, a benefits investigation is • If the patient is insured, docs/USP-BVP-2015-0153(2)_ conducted to determine an individ- SeaGen Secure will assist with SeaGen_Secure_PAP_Form_v07_ ual patient’s coverage for treatment. an appeal. If the appeal is clickable.pdf) has been completed, It is SeaGen Secure’s priority to make unsuccessful, the patient will fax it to: 855.557.2480. It is sure providers have patient-specific be assessed for eligibility for important that each field is filled coverage information before starting patient assistance. out completely and accurately to patients on therapy with Adcetris, so • If the patient is uninsured, the ensure timely processing of the ap- they will fax providers a summary patient will be assessed for plication. If you have any questions, of the patient’s Adcetris-related eligibility for the SeaGen Secure please call 855.4SEAGEN benefits within two business days Patient Assistance program. (855.473.2436), option 1, to speak of receiving the completed request. with a reimbursement counselor. If patient coverage for Adcetris is REIMBURSEMENT confirmed: ASSISTANCE Adcetris Co-Insurance • Refer to sample claims form SeaGen Secure reimbursement Assistance Program (https://seagensecure.com/assets/ services include: SeaGen Secure offers an assistance docs/Sample_CMS_1500_ • Billing and coding support. program for commercially insured ADCETRIS.pdf) for billing Trained reimbursement counsel- patients who have trouble affording guidance. ors provide payer-specific billing their co-insurance. Once an enroll- • If patients need help paying and coding requirements to ment form (seagensecure.medfor- co-insurance, they will be assist with the billing process. ward.com/FillOutForm.aspx? assessed for eligibility for the • Prior authorization assistance. formname=_Patient_Assistance_ SeaGen Secure Co-Insurance If it is determined that Adcetris and_Benefits_Investigation_ Assistance Program or referred treatment requires prior author- Request_Form) has been completed, to an independent foundation. ization, SeaGen Secure can fax it to: 855.557.2480. It is determine which forms and

76 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 77 TABLE OF CONTENTS Seattle Genetics

processes are needed to secure the authorization. Additionally, Tips for Filing Claims SeaGen Secure can track the prior authorization claim once For Electronic Claims DO… it is submitted. 3 • Appeal assistance and claims Verify, file, and keep all transmission reports. tracking. If an Adcetris prior 3 Track clearinghouse claims to ensure successful transmission. authorization or claim is denied (or partially paid), 3 Ensure your computer software is consistent with the clean SeaGen Secure will work to claims rules. determine the reason for the denial and the steps for an 3 Verify that your software correctly prints the CMS-1500 claim form. appeal. SeaGen Secure will 3 also provide a sample Letter Call your software vendor, if needed, to address the above of Medical Necessity (https:// two items. seagensecure.com/assets/ For Paper Claims DO… docs/ADCETRIS_Sample_ LMN_Appeal.pdf). Medical 3 Use only original claim forms (printed in red drop-out ink). Information may be able to assist with any additional data 3 Avoid folding claims, if possible. requests. After SeaGen Secure 3 assists with an appeal and the Resist using terms such as “refiled claim,” “second request,” documentation is submitted or “corrected claim.” to the payer, they offer claims 3 Avoid handwritten claims. tracking to ensure the payer receives the appeal and 3 Use all UPPERCASE letters. addresses it. Claims tracking ensures that the provider is 3 Stay inside the lines of each block. aware of claims payment and/or 3 any payer delays in processing. Ensure claims are printed darkly. • General payer and policy For Paper Claims DON’T… research. Many payers have established Adecetris policies. 3 Use any punctuation or decimals. Contact SeaGen Secure at 855.473.2436, option 1, from 3 Send unnecessary attachments. 9:00 am–8:00 pm EST, Monday 3 through Friday, to inquire Use staples or paperclips. about a specific payer's policy 3 Attach “post-it” notes. or obtain a copy of a current policy. 3 Mark up the claim with highlighters.

3 Use circles or additional markings.

3 Attach labels or stickers.

3 Add notes or instructional assistance.

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

ACCC 2017 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 the enrollment form in English at: appeals assistance if coverage taihopatientsupport.com/Home/ is denied. Taiho Oncology ViewPef or Spanish at: taihopatient • Specialty pharmacy Patient Support support.com/Home/ViewPefSp prescription coordination, Taiho Oncology Patient Support and fax the completed form to including prescription offers the following services: 1.844.287.2559. Questions? Call triage, coordination with the • Co-pay support for eligible, 844-TAIHO-4U (844.824.4648) in-network specialty pharmacy, privately insured patients. Monday through Friday, 8:00 am self-dispensing practice, or Such patients can receive a to 8:00 pm EST. Or visit: hospital retail pharmacy, and Taiho Oncology Patient Support taihopatientsupport.com. claims appeals assistance if Co-pay Card for help with coverage is denied. out-of-pocket expenses for REIMBURSEMENT • Personalized nurse support Lonsurf. ASSISTANCE is available for treatment plan • Patient Assistance Program. adherence upon request. Taiho Patient Support will Taiho Oncology Taiho Oncology Patient Support research financial assistance Patient Support treatment plan adherence ser- options for patients with no Taiho Oncology Patient Support vices are available as needed to insurance coverage, insuffi- will quickly investigate each support patient care, including cient prescription coverage, or patient’s coverage for Lonsurf refill reminders. insufficient resources to pay for and help them get access to the treatment with Lonsurf. Eligible Lonsurf treatment they have been To enroll in Taiho Oncology patients may receive Lonsurf prescribed. Taiho Oncology Patient Patient Support simply download at no cost based on assistance, Support offers the following the enrollment form in English at: financial, and medical criteria. services to help improve access to taihopatientsupport.com/Home/ • Alternate funding support. Lonsurf, and to make the treatment ViewPef or Spanish at: taihopatient Taiho Patient Support will also process as simple and smooth as support.com/Home/ViewPefSp refer eligible, publicly insured possible: and fax the completed form to patients to nonprofit founda- • Access and reimbursement 1.844.287.2559. Questions? Call tions that may be able to offer support, including benefit 844-TAIHO-4U (844.824.4648) them co-pay assistance. investigations, assistance with Monday through Friday, 8:00 am To enroll in Taiho Oncology prior authorizations to meet to 8:00 pm ET. Or visit: Patient Support simply download payer requirements, and claims taihopatientsupport.com.

78 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 79 TABLE OF CONTENTS Takeda Oncology

Takeda Oncology

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

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

PATIENT ASSISTANCE Application and a valid prescrip- requirements, however, there is no tion for Ninlaro. Patients must income limit for this program. This Ninlaro 1Point sign the form and submit the offer is valid for up to 13 prescrip- This comprehensive support required household verification. tion fills of Ninlaro per enrollment program offers an array of access If patients are approved for this year. This savings program covers and coverage services for patients program, they and their doctor out-of-pocket expenses greater and their healthcare providers. will be notified and a 1-month than $25 per monthly prescription. A dedicated case management supply of Ninlaro will be mailed Maximum value $25,000 annually. team helps patients and providers to them. Each month, the provider Co-pay cards can be renewed every navigate coverage requirements for must confirm that the patient is 12 months. This offer is not valid Ninlaro, streamline product access, still being treated with Ninlaro and with any other program, discount, and connect to helpful resources. requires another month’s supply. or incentive involving Ninlaro. This Services include the: Qualified patients may be enrolled offer may be rescinded, revoked, • Ninlaro Patient Assistance for up to 1 year. Get started or or amended without notice. No Program to learn more by calling 1.844. reproductions. This offer is void • Ninlaro Co-Pay Assistance N1POINT (1.844.617.6468) and where prohibited by law, taxed, or Program selecting option 2, Monday through restricted. Get started or to learn • Ninlaro RapidStart Program. Friday, 8:00 am-8:00 pm EST. Or more by calling 1.844.N1POINT download the enrollment form at: (1.844.617.6468) and selecting Ninlaro Patient https://www.ninlarohcp.com/pdf/ option 2, Monday through Friday, Assistance Program NINLARO1Point-PAP-Application. 8:00 am to 8:00 pm EST. Patients The Ninlaro Patient Assistance pdf and fax the completed form to: can also enroll by contacting their Program provides free medication 1.844.269.3038. designated specialty pharmacy. to eligible patients who do not After patients are enrolled, they have prescription drug or health Ninlaro Co-Pay will receive a letter in the mail from insurance coverage. If patients Assistance Program Ninlaro 1Point, containing their qualify for the program, Ninlaro Eligible, commercially insured co-pay card. will be delivered to them free of patients could pay as little as charge. To apply for the Patient $25 per monthly prescription of Ninlaro RapidStart Program Assistance Program, providers must Ninlaro, subject to a maximum The RapidStart Program can submit a completed and signed benefit of $25,000 annually. provide a 1-cycle (the number of Patient Assistance Program Patients must meet eligibility pills prescribed in a 28-day period)

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 79 TABLE OF CONTENTS Takeda Oncology

supply of Ninlaro for patients who documentation, as well as health • Referral to alternative experience a delay in insurance insurance information. It is strongly funding sources and coverage determination of at least recommended that you enroll third-party foundations 7 business days. Terms and condi- patients into the Patient Assistance • Connection to support services, tions apply. Physicians must submit Program prior to the start of their including referrals for transpor- a completed enrollment form and treatment with Velcade. All enroll- tation services, legal support, a valid prescription for Ninlaro ment forms must be received within and national and local organiza- to Ninlaro 1Point on behalf of six months of the first treatment. tions for counseling their patient. Patients must have The enrollment form is available • Ninlaro RapidStart Program for been prescribed Ninlaro for an online at: velcade.com/files/pdfs/ patients with insurance-related FDA-approved indication and VELCADE_VRAP_Enrollment_ coverage delays. be new to Ninlaro therapy. Patients Form.pdf. You can also obtain who have Medicare Part D or an enrollment form by calling The Velcade commercial insurance coverage may 1.866.VELCADE (1.866.835.2233) Reimbursement be eligible for this program. Get Monday through Friday, 8:00 Assistance Program started or to learn more by calling am-8:00 pm EST. Fax completed Dedicated (VRAP) case managers 1.844.N1POINT (1.844.617.6468) forms to: 800.891.9843. Learn help providers and patients: and selecting option 2, Monday more online at: velcade.com/Files/ • Verify patient’s insurance through Friday, 8:00 am to 8:00 pm PDFs/VRAP_and_Patient_ coverage. EST. Or download the enroll- Assistance.pdf or by calling 1.866. • Provide support during the ment form at: https://www.ninlaro VELCADE (1.866.835.2233) and appeals process in the event hcp.com/1point-program and choosing option 2. that a claim is denied (NOTE: fax the completed form to: VRAP case managers do not file 1.844.269.3038. REIMBURSEMENT claims or appeals on behalf of ASSISTANCE patients and cannot guarantee The Velcade Patient that patients will be successful Assistance Program Ninlaro 1Point in obtaining reimbursement). If patients do not have any This comprehensive support • Identify alternate and supple- insurance coverage, they may be program offers an array of access mental insurance coverage eligible to participate in the Velcade and coverage services for patients options. Patient Assistance Program. If and their healthcare providers. A • Provide co-payment foundation patients qualify for the program, dedicated case management team support information. Velcade will be delivered free of delivers personalized services • Screen and enroll eligible charge to their treating physician. that help patients and providers patients into the Velcade Patient Patient eligibility is based on three navigate coverage requirements for Assistance Program. factors: Ninlaro, streamline product access, • Connect patients to transporta- 1. Household income and connect to helpful resources. tion assistance. 2. Treatment setting Services include: 3. Velcade prescribed for a use • Benefit verification and prior The enrollment form is available that is medically appropriate. authorization assistance online at: velcade.com/files/pdfs/ • Assistance with appealing VELCADE_VRAP_Enrollment_ Patients who do not have insurance a payer denial Form.pdf. Fax completed forms coverage for Velcade must apply for • Ninlaro Co-Pay Assistance to: 800.891.9843. Learn more assistance through their healthcare Program enrollment for eligible, online at: velcade.com/Files/PDFs/ professionals. To demonstrate commercially insured patients VRAP_and_Patient_Assistance. eligibility, they must complete an • Specialty pharmacy referral pdf or by calling 1.866.VELCADE enrollment form and provide income and coordination (1.866.835.2233) and choosing

80 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 81 TABLE OF CONTENTS Takeda Oncology

option 2. Dedicated case managers are available Monday through Patient Assistance Checklist for Uninsured Patients Friday, 8:00 am to 8:00 pm EST. 3 I have received the chemotherapy order written by the physician? Resources for 3 I have met with the patient to assess his or her ability to pay for Healthcare treatment? Professionals 3 Based on this meeting, is the patient able to pay out-of-pocket for drug(s)? 1. A Quick Reference Guide con- q YES q NO taining information for payer If no, list drug(s) below and continue on with checklist. coding and payment informa- tion for Velcade: velcade.com/ 3 Is a replacement drug program available? q YES q NO files/pdfs/QRG_PI.pdf. If yes, identify drug and program: 2. Sample CMS-1500 Claim Form: velcade.com/files/pdfs/ 3 Does the patient qualify for this program? q YES q NO CMS-1500_withPI.pdf. If no, state reason(s) why: 3. Sample CMS-1450 (UB-04) Claim Form: velcade.com/files/ 3 If yes, I have completed all the necessary forms and paperwork for the pdfs/CMS-1450_withPI.pdf. drug replacement program. q YES q NO 4. Sample Letter Supporting If no, state reasons why: Medical Necessity for Velcade: velcade.com/files/pdfs/Med 3 Does the patient need drug(s) that are not available through a drug Necessity_withPI.pdf. replacement program? q YES q NO 5. Sample Letter Appealing a If yes, identify which drugs: Denied Claim for Velcade: velcade.com/files/pdfs/Appeal_ 3 Is Foundation funding assistance available for any of these drug(s)? withPI.pdf. q YES q NO 6. Sample Letter Appealing a If yes, identify Foundation(s) and drug(s): Denied Claim for Subcutaneous Injection: velcade.com/files/pdfs/ 3 I have completed all the necessary forms and paperwork for these NewSCLetter.pdf. 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. ACCC Financial Advocacy Network. accc-cancer.org/FAN

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 81 TABLE OF CONTENTS Tesaro, Inc.

Tesaro, Inc.

Oncology-related product: Varubi® (rolapitant), Zejula® (niraparib)

Patient and Reimbursement Assistance Website togetherwithtesaro.com

PATIENT AND evolve and grow to meet provider organizations, depending on patient REIMBURSEMENT and patient needs. eligibility. ASSISTANCE • Coverage Support: Includes Enrollment benefits investigation, prior TOGETHER with With the patient’s consent, authorization, and appeals TESARO™ enrollment begins when providers services. TOGETHER with TESARO is a complete and submit a simple • Patient Assistance Program patient resource program dedicated enrollment form. Enrollment (PAP): Provides product to supporting patients. The pro- forms can be obtained in print or to eligible uninsured and gramoffers a suite of solutions digitally through a case manager, underinsured patients who to address medication access and area manager, or https://www. have demonstrated financial affordability throughout each togetherwithtesaro.com. Enrollment hardship. Financial eligibility patient’s experience. TESARO’s initiates a comprehensive benefits requirements apply. expert case management team investigation with written findings • Commercial Co-Pay facilitates a seamless process to sent to the prescriber’s office. The Assistance Program: ensure TESARO patients get the report explains coverage status, Reduces out-of-pocket costs for individualized support needed. prior authorization requirement, commercially insured patients. and out-of-pocket costs for the The virtual card can be initiated Principles of the patient. This is a free service for all by enrolling in an online portal, Program patients enrolled in TOGETHER https://www.activatethecard. TOGETHER with TESARO is with TESARO. com/tesaro, which can also be based on 4 primary principles: found on https://www.together- commitment, the suite of solutions, TOGETHER with withtesaro.com. Card numbers seamless execution, and evolution. TESARO™ Suite of are registered and activated The program assists with access Solutions upon enrollment completion. issues so that patients can focus TOGETHER with TESARO offers • Referrals to Independent on treatment goals and daily life. a suite of solutions to address Co-Pay Foundations: Includes A team of access and affordabil- medication access and affordability, assistance with finding other ity experts is available to help including coverage support, Patient sources of financial support oncology practices and patients Assistance Program (PAP), Com- based on the patient’s eligibility gain access to the TESARO medi- mercial Co-Pay Assistance Program for these programs and services. cation they require. TOGETHER and referrals to independent co-pay with TESARO will continue to foundations and patient advocacy

82 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 83 TABLE OF CONTENTS Tesaro, Inc.

Patient Assistance Checklist for Medicare Only Patients

3 I have received the chemotherapy order written by the physician? 3 I have verified the patient’s insurance coverage? For more information about TOGETHER with TESARO, call 3 I have verified that the drug(s) are indicated for the patient’s diagnosis? 1.844.2TESARO (1.844.283.7276), 3 I have obtained prior authorization, if needed? or visit https://www.togetherwith- 3 I have identified the patient’s responsibility (an estimate in dollars) tesaro.com. for treatment costs? 3 I have met with the patient to assess his or her ability to pay for treatment? 3 Based on this meeting, does patient need drug replacement? q YES q NO

3 If yes, is a replacement drug program available? (Note: an appeal must to be made to receive drugs.) q YES q NO If yes, identify drug and program:

3 Does the patient qualify for this program? q YES q NO If no, state reason(s) why:

3 If yes, I have completed all the necessary forms and paperwork for the drug replacement program. q YES q NO If no, state reasons why:

3 Does the patient need drug(s) that are not available through a drug replacement program? q YES q NO If yes, identify which drugs:

3 Is Foundation funding assistance available for any of these drug(s) or to help with other treatment-related costs? q YES q NO If yes, identify Foundation(s) and drug(s):

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

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 83 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 877.237.4881, Monday through REIMBURSEMENT Friday, 9:00 am to 7:00 pm EST. ASSISTANCE The Teva Cares Then download the appropriate Foundation enrollment application for the Teva CORE The Teva Cares Foundation is a medication you have prescribed at: CORE (Comprehensive Oncology conglomeration of Patient As- tevacares.org/DownloadApplica Reimbursement Expertise) provides sistance Programs designed to tion.aspx. Completed applications patients and providers with a reim- improve patient access to Teva should be faxed to the number bursement support program, as medications and ensure that cost is provided at the top of the form. well as online tools to help make it not a barrier to care. Through these (NOTE: The fax number may differ easier to understand and navigate programs, the Teva Cares Founda- depending on the Teva medication.) reimbursement. The CORE Hotline tion is able to provide certain Teva (1.888.587.3263) is a service medications at no cost to patients in If your patient does not meet the provided by Teva Oncology to help the United States who meet certain eligibility requirements for the Teva physicians and their patients under- insurance and income criteria. Cares Foundation Patient Assis- stand the complexities of reim- Eligibility is based on a patient’s tance Programs, Teva may offer a bursement and where CORE fits income and prescription insurance reimbursement assistance program in. Reimbursement consultants are status, and varies depending on or other type of program to assist available 9:00 am to 8:00 pm EST, the Teva medication that has your patient. For more informa- Monday through Friday, to provide been prescribed. To determine if tion, please call 888.TEVA.USA assistance with the following: your patient qualifies, review the (838.2872). Some patients may be • Benefit verification and coverage Teva Cares Foundation Patient eligible for assistance from other determination Assistance Programs eligibility programs. For a listing of these • Pre-certification and prior autho- requirements online at: tevacares. other assistance programs go to: rization support org/DoIQualify.aspx or call tevacares.org/OtherResources.aspx.

84 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org TABLE OF CONTENTS TEVA Oncology

Patient Assistance Checklist for Medicaid Patients

3 I have received the chemotherapy order written by the physician? • Coverage guidelines and claim 3 requirements of payers I have verified the patient’s insurance coverage? • Personalized support through 3 I have verified that the drug(s) are indicated for the patient’s diagnosis? the claims and appeals process • Templates for letters of medical 3 I have obtained prior authorization, if needed? necessity • Referral to the appropriate 3 I have identified the patient’s responsibility (an estimate in dollars) Teva Cares Foundation Patient for treatment costs? Assistance Program. 3 I have met with the patient to assess his or her ability to pay for treatment?

Download the CORE enroll- 3 Based on this meeting, does patient need drug replacement? ment form at: tevacore.com/PDF/ q YES q NO Enrollment%20Form.PDF. Fax the completed form to 866.676.4073. If yes, is a replacement drug program available? (Note: an appeal must to Providers can also create an be made to receive drugs.) account and enroll their patients q YES q NO online at: https://eprescribe.iassist. If yes, identify drug and program: com/?style=tevaoncology.

3 Does the patient qualify for this program? q YES q NO If no, state reason(s) why:

If yes, I have completed all the necessary forms and paperwork for the drug replacement. 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:

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. ACCC Financial Advocacy Network. accc-cancer.org/FAN TABLE OF CONTENTS Other Patient Assistance Programs and Resources

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 receives 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. $17,820 (if single) and $24,030 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 2,500 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 $121.80. 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 the patient an cation form. Here are the types of continue.cfm. For more information individualized barcoded expenses patients may get help with: go to: benefitscheckup.org. application • Medications • Request documentation to • Food verify the patient's income.

86 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 87 TABLE OF CONTENTS Other Patient Assistance Programs and Resources

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

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 87 TABLE OF CONTENTS Other Patient Assistance Programs and Resources

copay.org. CCAF provides easy insured through federally adminis- Patient Online Application access to enrollment and can tered health plans such as Medicare, Portal available 24 hours a day. provide same-day approval. assisting them with prescription 2. Medical providers may apply drug co-payments, co-insurance, on behalf of their patients via Cancer Financial and deductibles required by the the Provider Online Application Assistance Coalition patient’s insurer. CPR call counsel- Portal available 24 hours a day. cancerfac.org ors work directly with the patient 3. Pharmacies may apply on as well as with the provider of behalf of their patients via the CFAC is a coalition of financial as- care to obtain necessary medical, Pharmacy Online Application sistance organizations joining forces insurance and income information Portal available 24 hours a day. to help cancer patients experi- to advance the application quickly. 4. The program offers personal ence better health and well-being Upon approval, payments may be service to all patients through by limiting financial challenges, made to: the use of an Approval Special- through: • The pharmacy ist, personally guiding patients 1. Facilitating communication and • The healthcare provider through the enrollment process collaboration among member • The patient directly. toll free at 866.512.3861, organizations Option 1. 2. Educating patients and Eligibility requirements: providers about existing • Patients must be insured and Good Days resources and linking to other insurance must cover the mygooddays.org organizations that can dis- medication for which they seek seminate information about assistance. Good Days has a mission to ensure the collective resources of the • Patients must have a confirmed no one has to choose between member organizations diagnosis of the disease or getting the medication they need 3. Advocating on behalf of cancer illness for which they seek and affording the necessities of patients who continue to financial assistance. everyday living. Good Days helps bear financial burdens associ- • Patients must reside and receive patients suffering from chronic ated with the costs of cancer treatment in the United States. diseases by providing financial treatment and care. • The patient’s income must fall support to patients who cannot below the income guidelines of afford the medications they need. Because CFAC is a coalition of the fund under which they are Services include: organizations, it cannot respond to requesting financial assistance. • Direct Financial Assistance for individual requests for financial as- All funds have income guide- patients who cannot afford their sistance. To find out if financial help lines of either 300 percent, 400 medication. Good Days offers is available, use the CFAC database percent, or less of the Federal a same-day approval process, at: cancerfac.org. Search by cancer Poverty Guideline with consid- so patients know on the same diagnosis or specific type of assi- eration of the Cost of Living day that they apply whether or stance or need (i.e., general living Index and the number in the not they have been approved. expenses, transportation, childcare). household. If approved, patients are given enough funding to cover their Co-Pay Relief NOTE: Patients will be informed treatments for the balance of copays.org immediately upon application if the calendar year. they qualify for assistance. • Premium Assistance to help The Patient Advocate Foundation patients find the insurance (PAF) Co-Pay Relief Program (CPR) The CPR Program offers four coverage that is right for them. provides direct financial support to points of entry: • Travel Assistance through the qualified patients, including those 1. Patients may apply via the Good Days Travel Concierge

88 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 89 TABLE OF CONTENTS Other Patient Assistance Programs and Resources

Program, which can help with certain medications and therapies. 3 Prescribing physician informa- transport, lodging and ancillary If patients have some healthcare tion (name, address, telephone travel costs for patients who coverage, either through a private number, fax number, and must travel to receive treatment. insurance plan or a federal or state- contact name) funded program such as Medicare 3 Fund to which the patient is Please note, because Good Days is a or Medicaid, but still cannot afford applying for assistance non-profit charitable organization, the out-of-pocket costs associ- 3 Type of assistance the patient it cannot guarantee that funding ated with their medical treatment, is applying for (co-pay or for a specific disease state will be HealthWell may be able to help. premium). available. However, if unable to provide financial help, Good Days With the patient’s permission, NOTE: not all funds offer premium will refer patients to outside orga- providers, pharmacy representa- assistance. nizations that may be able to offer tives, and patient advocates assistance instead. can apply on behalf of a patient The HealthWell Foundation pro- in two ways: vides instant approval for patients For a list of covered diseases and 1. Apply online using the applying online or via phone. medications go to: http://www. HealthWell provider portal at: (Online applications can take up mygooddays.org/for-patients/ https://healthwellfoundation. to one business day to process; diseases-and-medications-covered/. secure.force.com/ patients and providers who apply Enrollment applications can be 2. Apply by phone at: over the phone can expect to know downloaded online at: https:// 800.675.8416. of their approval status within www.mygooddays.org/wp-content/ 10 to 15 minutes.) If approved, uploads/2017/03/Internet-Applica- NOTE: Providers, pharmacies, HealthWell will send an approval tion_v20170321.pdf (English) or and social workers are strongly letter with the enrollment period https://www.mygooddays.org/wp- encouraged to use the Provider dates and grant amount to the content/uploads/2017/03/Internet- Portal to apply so that patients can patient. The approval letter will Application_v20170321_Spanish. readily access HealthWell hotline provide the patient with a Reim- pdf (Spanish). (Please note: Enroll- care managers. Before beginning bursement Request Form based ment applications may change from the application process, have the on the type of assistance requested year to year.) Or providers and following information ready: and instructions for submitting patients can apply online at: http:// 3 Patient contact information the reimbursement OR a pharmacy patientsandpros.mygooddays.org/. (name, address, telephone card (fund appropriate). In ad- Questions? Call 877.968.7233, number, Social Security number, dition, HealthWell will fax a copy Monday through Friday, 8:00 date of birth). of the approval letter to the pro- am-5:00 pm CST. vider as long as their fax number NOTE: If patient does not have a was provided. HealthWell Foundation Social Security number, providers healthwellfoundation.org should call 800.675.8416 to speak NOTE: The HealthWell Founda- with a HealthWell representative. tion randomly selects patients for The HealthWell Foundation reduces income audits and confirmation financial barriers to care for under- 3 Patient insurance and prescrip- of diagnosis. It is very important insured patients with chronic or tion information and ID (i.e., for patients to understand that if life-threatening diseases by provid- insurance and policy informa- they receive a letter from Health- ing financial assistance to eligible tion and prescription card(s) Well at any time requesting income individuals to cover the cost of 3 Patient income information documentation, they must reply co-insurance, co-payments, health- (total household income, total right away. If they don’t, payments care premiums, and deductibles for household size) on their grant will stop or their

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 89 TABLE OF CONTENTS Other Patient Assistance Programs and Resources

HealthWell Pharmacy Card will • Blood cancer treatment-related NeedyMeds be de-activated. In addition, the co-payments needymeds.com patient will have to submit income • Private health insurance documentation to HealthWell for premiums NeedyMeds is a non-profit informa- any and every new grant moving • Medicare Part B, Medicare Plan tion resource dedicated to helping forward. Individuals applying on D, Medicare Supplementary people locate assistance programs behalf of a child for the Pediatric Health Insurance, Medicare to help patients afford their medica- Assistance Fund will not receive Advantage premium, Medicaid tions and other healthcare costs. immediate grant approval. For spend-down, or co-pay Each program has its own qualify- more information on the Pediatric obligations. ing criteria. To find a PAP that you Assistance Fund application process may qualify for click on the brand visit: healthwellfoundation.org/ To be eligible for Co-Pay Assistance, name or generic name drug under pediatric-assistance-fund. patients must: the “Patient Savings” tab on the 3 Have a household income at or NeedyMeds website, or search for When a patient applies and is below 500 percent of the U.S. your medication name using the approved for assistance, the grant Federal Poverty Guidelines as search feature in the upper lefthand start date can be up to 30 days adjusted by the Cost of Living corner of the screen. If using the prior to the application date. All Index “Patient Savings” tab: active grant recipients are welcome 3 Be a United States citizen or 1. Click on the first letter of the to re-enroll at the end of their grant permanent resident of the U.S. name of your medicine in the cycle (one year) as long as assistance or Puerto Rico and be medically alphabet bar. is still required and the individual and financially qualified 2. Click on the name of your still meets the program criteria and 3 Have medical and/or prescrip- medicine to find out if there is funding is available. Patients can tion insurance coverage a Patient Assistance Program begin the re-enrollment process no 3 Have an LLS Co-Pay Assis- (PAP) available. If there is an more than 3-4 weeks in advance of tance Program covered blood active program available, a PAP the end date of their current grant. cancer diagnosis confirmed by icon will appear under the drug a provider (See a list of covered name. Questions? Call 800.675.8416 diagnoses here: http://www.lls. 3. Click on the PAP icon to access to speak with a HealthWell repre- org/support/financial-support/ the eligibility and contact sentative, 9:00 am-5:00 pm EST, co-pay-assistance-program). information for the program(s). Monday through Friday. In some cases, the program Apply online at: application form can be printed The Leukemia & https://cprportal.lls.org/ from the NeedyMeds website. Lymphoma Society Applications should be faxed or lls.org You can also apply or get more mailed directly to the PAP, not information about the LLS Co-Pay to NeedyMeds. The Leukemia & Lymphoma Assistance Program, by calling 4. PAPs can also be found by Society (LLS) Co-Pay Assistance 877.557.2672 and speaking with a searching the Program Name Program helps patients pay their co-pay specialist who will provide List OR by looking through insurance premiums and meet personalized service throughout the the Company Name List, co-pay obligations. LLS can also application process. both found under the “Patient help providers and patients find Savings” tab on the NeedyMeds additional sources of financial website. support. The LLS Co-Pay Assis- 5. If an application form is tance Program offers financial help available through a PAP, look toward: for it in the Program Applica-

90 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 91 TABLE OF CONTENTS Other Patient Assistance Programs and Resources

tions list. Look for all of your free and available to everyone. the cost of healthcare. NeedyMeds medications, not just the most There is no registration and has compiled a database of these expensive ones. your entire family can use state programs. The programs the same card. Download a are available via the organiza- Applications Assistance: card and learn more about its tion website. You can search these If you need help filling out your benefits. Information on other programs by clicking on a state, applications, see our list of organiza- drug discount cards are also the District of Columbia, Puerto tions that provide application assi- available on the NeedyMeds Rico, or Guam. Programs and their stance for free or a small fee here: website. guidelines vary from state to state. http://www.needymeds.org/local- • Diagnosis-Based Assistance: NeedyMeds has also has a list of programs. These organizations can needymeds.org/copay_branch.taf. Medicaid Sites with a clickable map help with such things as finding a There are many government and where you can learn more about program for your prescription med- private-funded programs that Medicaid in your state, as well as ication, completing the application help with costs associated with general information on Medicare. forms, and working with physicians a specific diagnosis. They may who must sign the forms. You can cover many types of expenses, For all help line questions, send find local programs in two ways: including drugs, insurance emails to [email protected] 1. Enter the patient’s ZIP code to co-pays, office visits, transporta- or call our toll-free number: find a program in their area or tion, nutrition, medical supplies, 1.800.503.6897. 2. Search by state. child, or respite care. Some cover one specific diagnosis, while Partnership for If your medicine does not appear on others cover whole categories Prescription Assistance the brand name or generic name lists, (such as all types of cancers) or pparx.org then it is not available through a PAP. even all chronic medical illnesses. Other assistance options include: Some programs are national in The Partnership for Prescription • Coupons, Rebates & More scope, while others are limited Assistance (PPA) helps qualify- are offered by various drug to people in specific states. Most ing uninsured and underinsured companies and may offer a have some type of eligibility patients connect to the right assi- rebate, discount or even free requirements, usually financial stance programs so that they can trial size of a medication. Offers ones. NeedyMeds has compiled get the medicines they need for free for prescription medications a database of diagnosis-based or nearly free. The Partnership for require a doctor's prescription. assistance programs that you Prescription Assistance will help Offers can be found three ways: or your patient can search. It’s you find the program that’s right under Brand Name Drugs if a best to search by the type of for your patient, free of charge. coupon icon appears under the diagnosis. Other ways to search drug name then click on the for assistance are by looking for Step 1. Tell us what medicines your icon. They can also be found on programs that serve a specific patient takes. Go to: www.pparx. the Coupons, Rebates & More geographical area. If you know org/gethelp/select-therapies. Type page of the NeedyMeds website. the name of a specific program the name of the medicine into the Use the alphabet bar to find about which you want more in- box and click the search button. the medicine. Or do a category formation, you can also search Once the search is complete you search for coupons by diagnosis by name of program. can add one or more prescription or symptoms. drugs from your search to the My • NeedyMeds Drug Discount Assistance with Medicines list, which appears on Card provides savings of up Government Programs: the right side of the page. Repeat to 80% on many prescrip- Every state has programs to help this process until you have entered tion medications. The card is needy families and individuals with and selected all of the medicines.

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 91 TABLE OF CONTENTS Other Patient Assistance Programs and Resources

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

92 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 93 TABLE OF CONTENTS Other Patient Assistance Programs and Resources

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

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 93 TABLE OF CONTENTS Other Patient Assistance Programs and Resources

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

94 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 95 TABLE OF CONTENTS Other Patient Assistance Programs and Resources

RxAssist Prescription • The patient’s first and the house, add $12,420/year. Discount Card last name. (Alaska: add $15,540/year; Patients can save up to 80 percent Hawaii: add $14,280/year.) off the cash price of their medica- Once you have the above informa- tions using the RxAssist Prescrip- tion available, go to: www.rxhope. Providers and patients can enroll tion Discount Card at their local com/Prescriber/Register.aspx and in the program by following the pharmacy. 21 of 25 most common follow the instructions. You will be steps below: meds are cheaper with the card setting up your free account and than a $10 co-pay. This card: creating an order for your patient 1. Determine patient eligibility • Is completely free and all at the same time. using criteria above. never expires 2. See if the patient’s drug is • Works for all FDA-approved Rx Outreach® listed on the RxOutreach prescription medications rxoutreach.org Medication’s List: rxoutreach. • Supports RxAssist.org. org/find-your-medications. Rx Outreach is a fully-licensed 3. Create a simple account by Learn more at: rxassist.org/patients/ non-profit mail order pharmacy providing your email address patient-assistance-center. that ships medication directly to and selecting a password. Verify patients’ homes. To make this the email address provided. RxHope™ process simple and cost-effective, 4. Enroll in Rx Outreach. To rxhope.com Rx Outreach typically ships a 90 or enroll, you’ll need to provide 180-day supply of the needed medi- the following information: Healthcare providers and their staff cation. Patients who meet eligibility • Name and contact infor- can set up accounts online to order requirements can use Rx Outreach mation for provider and free medications for their patients regardless of whether they use patient through the RxHope automated Medicare, Medicaid, or other • Patient date of birth patient assistance online system. health insurance. To be eligible to • Patient Social Security If you would like to create a free use Rx Outreach, patients must or Green Card number account for one healthcare provider, meet income requirements, which (required to order visit: rxhope.com/Prescriber/Set differ depending on household size: Controlled Substance upAccount.aspx. (NOTE: Each • 1-person household: Less than medications only) account is valid for use by one $35,640 /year. (Alaska: less than • Information on patient healthcare provider only. If multiple $44,520 /year; Hawaii: less than allergies and current members of your office staff wish $41,010/year.) medications to utilize the RxHope automated • 2-person household: Less than • Patient income and patient assistance online system, $48,060 /year. (Alaska: less than household size information each staff person must set up a $60,060 /year; Hawaii: less than • For faster service, you can separate account.) To set up your $55,290/year.) include credit card infor- free account and place orders online • 3-person household: Less than mation for payment at the following criteria are required: $60,480 /year. (Alaska: less than this time. • You must be a healthcare $75,600/year; Hawaii: less than 5. Follow Rx Outreach guidelines, provider or their staff $69,570/year.) found at http://rxoutreach.org/ • A valid state license number for • 4-person household: Less than wp-content/uploads/current/ the healthcare provider $72,900 /year. (Alaska: less than Overview.pdf, when writing • An email address (this will $91,140 /year; Hawaii: less than patient’s prescription. It is become your login) $83,850/year.) important that the patient’s pre- • The medication for which the • More than 4-person household: scription is written according patient is applying For each additional person in to these guidelines.

ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org / 95 TABLE OF CONTENTS Other Patient Assistance Programs and Resources

6. Calculate the cost of your can also be submitted online or For more information, go to: medication(s) by filling over the phone. Once payment rxoutreach.org or call out the worksheet found and prescription are received, 1.888.RXO.1234 at http://www.rxoutreach. please allow 24 to 48 hours for (1.888.796.1234), Monday through org/, using the information processing. Friday, 7:00 am to 5:30 pm CST. provided here: rxoutreach.org/ find-your-medications. 7. Fill out and sign the Rx Outreach form. Patients will Tips for Assisting Patients in Applying to Patient need to submit a separate Assistance Programs form for each member of their household who orders medica- tion. Medications can be sent 3 If you have any questions, call the program directly. Eligibility directly to the patient’s home, requirements, drugs, dosages, even programs, change regularly so it’s or to the provider’s office. best to go directly to the program for information. If you do not qualify To obtain additional forms for the PAP but cannot afford your medicine, tell the representative. call 1.888.RXO.1234 Some companies may make hardship exceptions and are willing to (888.796.1234). Monday review situations on a case-by-case basis. Sometimes you can write through Friday, 7:00 am to an appeal letter to the program explaining your financial hardship. 5:30 pm CST or visit the Rx Outreach website. 8. Submit prescription, payment 3 Review the Federal Poverty Guidelines and Percentages over the Poverty and form to Rx Outreach. Guidelines when looking at the eligibility guidelines of a program. Payment can be made with personal checks, money orders, 3 Fill out as much information on the application as possible, including or credit cards (only Visa, the doctor’s address and phone number. Highlight the directions for MasterCard, or Discover). the doctor and where he or she needs to sign. Give the doctor’s office Patients are asked not to send an addressed-and stamped-envelope to send in the application or cash. Patients should send highlight the fax number so it is easy to find. payment for the total cost of their medication(s) along with completed Rx Outreach 3 Plan ahead so your medicine supply doesn’t run out. When sending in form and prescriptions. an application, pay attention to the refill process and the amount of (NOTE: If patient has health allowable refills. Each program is different; some require a call from the insurance, they cannot use their doctor’s office while another may allow the patient to call directly for insurance to help pay the Rx a refill; others may require a new application, which takes time. Outreach fee.) Prescriptions and payment may be faxed to 3 Be neat and complete. The directions on the application should be 1.800.875.6591. Faxed pre- completed exactly as directed. Print neatly. If something is unreadable scriptions are only accepted or there is a blank, then the application may be denied, which can delay from a healthcare provider’s the process of receiving the medicine. Put “N/A” or “not applicable” in office or facility. Patients or blanks that are not filled out to indicate the material was read through providers can also mail pre- and not skipped over. Include supplementary forms if requested. Make scriptions and payment to: Rx sure all accompanying photocopies are clean and readable. Outreach, P.O. Box 66536, St. Louis, MO, 63166-6536. Credit or debit card payment Source. ACCC Financial Advocacy Network. accc-cancer.org/FAN

96 / ACCC 2017 Patient Assistance and Reimbursement Guide I accc-cancer.org TABLE OF CONTENTS

Supporting Patients Through Their Journey on Jakafi® (ruxolitinib)

IncyteCARES (Connecting to Access, Reimbursement, Education and Support) provides a single point of contact through a registered nurse, OCN®, to assist eligible patients and healthcare providers in obtaining access to Jakafi® (ruxolitinib) and to connect them with continuing support and resources. The program offers:

REIMBURSEMENT SUPPORT • Insurance benefit verification • Information about prior authorizations • Guidance with appealing insurance denials or coverage restrictions

ACCESS ASSISTANCE • Copay/Coinsurance assistance • Free medication program • Temporary access for insurance coverage delays • Referrals to independent nonprofit organizations and foundations

EDUCATION & SUPPORT • Access to a registered nurse, OCN® • Educational information for your patients about their condition and Jakafi • Patient Welcome Kit

CONNECTION TO SUPPORT SERVICES • Referrals for transportation assistance • Access to patient advocacy organizations for counseling and emotional support resources

Connect with IncyteCARES For full program terms and eligibility, visit IncyteCARES.com or call 1-855-4-Jakafi (1-855-452-5234).

Jakafi is a registered trademark of Incyte Corporation. © 2016, Incyte Corporation. All rights reserved. RUX-1887 08/16

RUX-1887_OverviewJrnlAd_ACCC-OncologyIssues_8x10-75_x1a.indd 1 9/22/16 11:19 AM ©2017. Association of Community Cancer Centers. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means without written permission. Although every effort has been made to ensure the accuracy and completeness of this guide, ACCC is not responsible for any errors or omissions contained within. Inclusion of companies in this publication does not serve as an endorsement by ACCC of the company, its products, or its services. 1801 Research Boulevard, Suite 400 Rockville, MD 20850 301.984.1242 y accc-cancer.org