Reimbursement Guide

ASSOCIATION OF COMMUNITY CANCER CENTERS

Patient & Reimbursement Guide

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 1 ASSOCIATION OF COMMUNITY CANCER CENTERS

Patient & Reimbursement

3 Financial Toxicity Navigation Process Improvement Guide by Natasha Gomes

8 Patient Assistance Program Flowchart

Pharmaceutical Company Patient Medical Device & Testing Patient Assistance & Reimbursement Programs Assistance & Reimbursement Programs AbbVie, Inc. 13 Adaptive Biotechnologies 74 Amgen, Inc. 14 Foundation Medicine 75 Array BioPharma 16 Astellas Pharma US, Inc. 17 Other Patient Assistance Programs & Resources AstraZeneca 19 Agingcare.com® 78 Bayer HealthCare Pharmaceuticals, Inc. 21 BenefitsCheckUp® 78 Boehringer Ingelheim Pharmaceuticals, Inc. 24 CancerCare® 78 Bristol-Myers Squibb 26 CancerCare® Co-payment Assistance Foundation 79 Celgene Oncology 28 Cancer Financial Assistance Coalition 79 Coherus BioSciences 30 Co-Pay Relief 80 Eisai Co., Ltd. 32 FamilyWize® 80 Eli Lilly and Company 34 Good Days® 80 EMD Serono, Inc. and Pfizer, Inc. 37 HealthWell Foundation® 81 Exelixis, Inc. 39 The Leukemia & Lymphoma Society 82 Genentech, Inc. 41 NeedyMeds 82 Heron Therapeutics 43 Partnership for Prescription Assistance 83 Incyte Corporation 45 Patient Access Network Foundation 84 Ipsen Biopharmaceuticals, Inc. 47 Patient Advocate Foundation 84 Janssen Biotech, Inc. 49 RxAssist 85 Kite Pharma 52 RxHope™ 85 Merck 53 Rx Outreach® 85 Mylan 55 Novartis Pharmaceuticals Corporation 57 Pfizer, Inc. 59 Pharmacyclics, LLC 61 Puma Biotechnology 62 Regeneron Pharmaceuticals, Inc. and Sanofi Genzyme 63 Sandoz, Inc. 65 Seattle Genetics 66 The ACCC Patient Assistance & Reimbursement Guide was Taiho Oncology 67 printed in January 2019. This publication is updated four times Takeda Oncology 68 a year. Visit accc-cancer.org/PatientAssistanceGuide to Tesaro, Inc. 71 download and print the most up-to-date information on cancer drug assistance and reimbursement programs. Teva Oncology 73

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 1 Patient Assistance and Reimbursement Assistance Programs by Drug or Product

Abraxane® (paclitaxel protein-bound particles Farydak® (panobinostat) capsules 57 for injectable suspension) (albumin-bound) 28 Faslodex® (fulvestrant) 19 Actiq® (oral transmucosal fentanyl citrate) [C-II] 73 Femara® (letrozole) tablets 57 Adcetris® (brentuximab vedotin) for injection 66 Fentora® (fentanyl buccal tablet) [C-II] 73 Afinitor® (everolimus) tablets 57 Fulphila® (pegfilgrastim-jmdb) injection 55 Afinitor Disperz® (everolimus) tablets for Gardasil®9 (Human Papillomavirus 9-valent oral suspension 57 Vaccine, Recombinant) 53 Alecensa® (alectinib) capsules 41 Gazyva® (obinutuzumab) 41 Alimta® (pemetrexed for injection) 34 Gilotrif® (afatinib) 24 Aliqopa™ (copanslib) for injection 21 Gleevec® (imatinib mesylate) tablets 57 Aloxi® (palonosetron hydrochloride) injection 32 Granix® (tbo-filgrastim) for injection 73 Alunbrig® (brigatinib) tablets 68 Halaven® (eribulin mesylate) 32 Aranesp® (darbepoetin alfa) 14 Herceptin® (trastuzumab) 41 Aromasin® (exemestane) tablets 59 Herceptin Hylecta™ (trastuzumab and Arzerra® (ofatumumab) injection 57 hyaluronidase-oysk) 41 Avastin® (bevacizumab) 41 Ibrance® (palbociclib) 59 Balversa™ (erdafitinib) 49 Iclusig® (ponatinib) 68 Bavencio® (avelumab) injection 37, 59 Idamycin PFS® (idarubicin hydrochloride) Bendeka® (bendamustine hydrochloride) for injection 59 for injection 73 Idhifa® (enasidenib) 28 Besponsa® (inotuzumab ozogamicin) for injection 59 Imbruvica® (ibrutinib) 61 Blincyto® (blinatumomab) 14 Imfinzi® (durvalumab) injection 19 Bosulif® (bosutinib) tablets 59 Imlygic® (talimogene laherparepvec) suspension Braftovi® (encorafenib) capsules 16 for intralesional injection 14 Cabometyx® (cabozantinib) tablets 39 Inlyta® (axitinib) tablets 59 Calquence® (acalabrutinib) 19 Intron® A (interferon alfa-2b, recombinant) Camptosar® (irinotecan hydrochloride injection) 59 for injection 53 Cinvanti® (aprepitant) injectable emulsion 43 Iressa® (gefitinib) 19 Cometriq® (cabozantinib) capsules 39 Jadenu® (deferasirox) tablets 57 Cotellic® (cobimetinib) tablets 41 Jakafi® (ruxolitinib) tablets 45 Cyramza® (ramucirumab) 34 Kadcyla® (ado-trastuzumab emtansine) 41 Darzalex® (daratumumab) 49 Keytruda® (pembrolizumab) 53 Daurismo™ (glasdegib) 59 Kisqali® (ribociclib) tablets 57 Doxil® (doxorubicin HCl liposome injection) 49 Kymriah® (tisagenlecleucel) suspension Ellence® (epirubicin hydrochloride injection) 59 for IV infusion 57 Emcyt® (estramustine phosphate sodium Kyprolis® (carfilzomib) for injection 14 capsules) 59 Lartruvo® (olaratumab) 34 Emend® (aprepitant) 53 Lenvima® (lenvatinib) capsules 32 Emend® (fosaprepitant) for injection 53 Libtayo® (cemiplimab-rwlc) 63 Empliciti® (elotuzumab) 26 Lonsurf® (trifluridine and tipiracil) tablets 67 Erbitux® (cetuximab) 34 Lorbrena® (lorlatinib) 59 Erleada™ (apalutamide) 49 Lumoxiti™ (moxetumomab pasudotox-tdfk) 19 Erivedge® (vismodegib) 41 Lupron Depot® (leuprolide acetate for depot Exjade® (deferasirox) tablets 57 suspension) 13

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 1 Patient Assistance and Reimbursement Assistance Programs by Drug or Product (continued)

Lynparza® (olaparib) tablets and capsules 19 Tecentriq® (atezolizumab) for injection 41 Mektovi® (binimetinib) tablets 16 Temodar® (temozolomide) 53 Mekinist® (trametinib) tablets 57 Thalomid® (thalidomide) 28 Mylotarg™ (gemtuzumab ozogamicin) Torisel® (temsirolimus) for injection 59 for injection 59 Trazimera™ (trastuzumab-qyyp) 59 Nerlynx® (neratinib) 62 Treanda® (bendamustine HCl) for injection 73 Neulasta® (pegfilgrastim) 14 Trisenox® (arsenic trioxide) for injection 73 Improving patient flow Neupogen® (filgrastim) 14 Tykerb® (lapatinib) tablets 57 by optimizing EHRs Nexavar® (sorafenib) tablets 21 Udenyca™ (pegfilgrastim-cbqv) 30 Ninlaro® (ixazomib) capsules 68 Vectibix® (panitumumab) 14 Nplate® (romiplostim) 14 Velcade® (bortezomib) for injection 68 Odomzo® (sonidegib) 57 Venclexta® (venetoclax) 41 Onivyde® (irinotecan liposome injection) 47 Verzenio® (abemaciclib) 34 Opdivo® (nivolumab) 26 Vidaza® (azacitidine) 28 Perjeta® (pertuzumab) for injection 41 Vitrakvi® (larotrectinib) 59 Pomalyst® (pomalidomide) 28 Vizimpro® (dacomitinib) 59 Portrazza® (necitumumab) 34 Votrient® (pazopanib) tablets 57 Procrit® (epoetin alfa) 49 Xalkori® (crizotinib) capsules 59 Prolia® (denosumab) 14 Xgeva® (denosumab) 14 Promacta® (eltrombopag) tablets 57 Xofigo® (radium Ra 223 dichloride) injection 21 Revlimid® (lenalidomide) 28 Xospata® (gilteritinib) tablets 17 Rituxan® (rituximab) 41 Xtandi® (enzalutamide) capsules 17 Rituxan Hycela® (rituximab/hyaluronidase human) Yervoy® (ipilimumab) 26 for injection 41 Yescarta® (axicabtagene ciloleucel) suspension Rydapt® (midostaurin) 57 for infusion 52 Sandostatin® (octreotide acetate) for injection 57 Yondelis® (trabectedin) 49 Sandostatin® LAR Depot (octreotide acetate Zarxio® (filgrastim-sndz) 65 for injectable suspension) 57 Zejula® (niraparib) 71 Sensipar® (cinacalcet) 14 Zelboraf® (vemurafenib) 41 Somatuline® Depot (lanreotide) for injection 47 Zinecard® (dexrazoxane) for injection 59 Sprycel® (dasatinib) 26 Zolinza® (vorinostat) 53 Stivarga® (regorafenib) tablets 21 Zykadia® (ceritinib) capsules 57 Sustol® (granisetron) extended-release injection 43 Zytiga® (abiraterone acetate) 49 Sutent® (sunitinib malate) 59 Sylatron® (peginterferon alfa-2b) for injection 53 Sylvant® (siltuximab) 49 Synribo® (omacetaxine mepesuccinate) for injection 73 Tafinlar® (dabrafenib) capsules 57 Tagrisso® (osimertinib) 19 Talzenna® (talazoparib) 59 Tarceva® (erlotinib) 17, 41 Tasigna® (nilotinib) tablets 57

2 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 3 Financial Toxicity NavigationBY NATASHA GOMES Process Improvement FINANCIAL TOXICITY NavigationImproving patient Process ﬂow by Improvement optimizing EHRs Improving patient flow by optimizing EHRs

inances are often a major concern for patients electronic health record (EHR) has allowed us to manage dealing with a cancer diagnosis. In 2017 DuPage this heavy caseload. Medical Group, Downers Grove, Ill., directed more attention and resources toward our financial Leveraging our Epic EHR to better support financial Fnavigation department to assist patients in minimizing navigation of patients along the care continuum, DuPage out-of-pocket expenses. Adding financial navigators Medical Group is able to: to the conversation and communication process helps • Capture patients from the time an order for bridge the gap for a patient deciding whether to start treatment is placed or continue treatment, as financial navigators provide • Develop communications with oncology and patients with exceptional, personalized care and guid- infusion patients ance throughout the course of their treatment. This also • Follow up on patient accounts eases the burden on our clinical staff by allowing them to • Track billing to co-pay assistance programs and focus on their areas of expertise. foundations.

DuPage Medical Group is the largest physician-owned Since implementing this process in June 2017, DuPage group in Illinois, with more than 700 physicians, 115 Medical Group has tripled patient enrollment in co-pay locations, and 6 infusion sites that average 700 scheduled and foundation assistance programs, helping reduce appointments per week. Medical oncology and radiation patient expenses by $1.4 million. The following outlines oncology services are staffed by 11 physicians and more our new workflow for patient financial navigation and than 100 clinical staff. With a team of only 4 financial offers guidance for cancer programs seeking to imple- navigators supporting all specialties, much is expected of ment a financial assistance pathway. our financial navigation team. However, optimizing our

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 3 Financial Navigator Intake Process

Physician orders a new or updated treatment/therapy plan through EHR

Order routed to Health Plan Services work queue to begin prior authorization

Mirrored work queue created for ﬁnancial navigator to access authorized referral, sorted by patient last name

Financial navigator reviews patients with authorized referrals for co-pay or foundation assistance

Financial navigator transfers patient to personal work queue and removes patient from mirrored work queue

Financial navigator uses two account statuses to track patient in EHR and track patient’s co-pay or foundation enrollment

EHR routes account based on status code to biller work queue

Biller handles patient submittal to co-pay or foundation assistance for reimbursement

4 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 5 CAPTURING PATIENTS FROM THE TIME OF ORDER status code to ensure that patients are routed appropri- Once it has been determined that a patient needs to ately to the billing work queue. start a treatment/therapy plan, an order is placed by the FINANCIAL NAVIGATOR RESPONSIBILITIES physician’s office through a module in the EHR called Beacon. That order is then routed to our Health Plan Financial navigators use two account statuses: one to Services work queue to start the prior authorization track patients in the EHR, and one for Patient Accounts to process. In addition to the work queue for Health Plan know if a patient has an active co-pay foundation enroll- Services, we created a work queue for financial naviga- ment. While not all patients qualify for co-pay programs tors so that they can view the same information that our or foundation assistance, we assign a status code and Health Plan Services department sees. By creating this track all patients anyway. In the background, the EHR mirrored work queue, our financial navigation team can will route that status code to a work queue assigned to review all patients with authorized referrals to deter- our biller, who handles submittal to co-pay programs and mine if patients qualify for co-pay/foundation assistance foundations for reimbursement. and begin the enrollment process. Financial navigators will transfer this patient to their personal work queue For patients who do not qualify, we use another status and change the referral flag to “benefits verified,” code so we know the patient is in active treatment removing the patient from both the Health Plan Services but does not currently qualify for any assistance. and the mirrored queue. Even if patients do not qualify for assistance, we still want to be available to assist with billing questions DEVELOPING A WORKFLOW FOR FINANCIAL and payment arrangements and to monitor founda- NAVIGATORS tion funds in the event that one opens up for which a It was determined that best practice for managing patient qualifies. patients was to develop an alpha split process based on patient last name to assign patients to a financial navi- Financial navigators monitor and review all patients gator who would serve as the liaison for the patient and in their work queue who are in active treatment. A clinical staff. Regardless of physician and location, each reminder date can be set to review each patient’s account patient has a designated financial navigator to assist (usually every 30 days) to make sure the patient is not with any billing questions or financial concerns. receiving any denials and that payment arrangements Assigning patients to a financial navigator provides are current. The following financial navigation work a single point of contact and streamlines the admin- queues are built in the EHR: istrative process. Through the EHR, patients are • Financial navigator work queue. Based on alpha split entered into their financial navigator’s work queue, (total of four work queues) to monitor and review all eliminating the use of spreadsheets for tracking and patients for oncology/infusion. allowing financial navigators to easily provide backup • Oncology/Infusion closed foundations. Patients that for each other. Activity codes were built into the EHR are in active treatment, but the foundation is closed. for patient account notes, and financial navigators A work queue is created for closed foundations, have assigned activity codes along with smart phrases notifying a financial navigator if/when they open (a series of questions) so that the note is standardized again. At that point, we can access the work queue yet comprehensive. Reports can be pulled by manage- and try to assist those patients. A specific activity ment for tracking purposes, to monitor enrollment, for code denotes that a fund in which the patient was use of activity codes and letters, and to follow up with enrolled has been closed. billing questions, ensuring that each patient has been • Oncology review work queue. We added all J codes reviewed. Each activity code can also show an attached (and some Q codes) for oncology and infusion

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 5 patients that have a self-pay balance. In the event an TRACKING AND BILLING CO-PAY AND FOUNDATION enrollment is missed, this catch-all work queue will PAYMENTS capture a patient and add them. We have one biller for the submittal of claims and EOBs that works with co-pay and foundation programs for Financial navigators will try to contact the patient reimbursement. The biller will review the financial via phone and introduce themselves, explaining that navigator enrollment note based on what drops into co-pay/foundation assistance may be available. We also the biller work queue. This work queue was designed have walk-in availability by appointment or by phone. to catch all patients that have been enrolled into co-pay DuPage Medical Group social workers work closely with or foundations and allows the biller to focus solely on the patient, and in the event of financial need, they will reimbursement. notify financial navigators that the patient needs assistance through a message pool in the EHR. By stream- Tracking payments from co-pay and foundation used to lining this process, patients have greater communication be a challenge. Prior to having a payment code built into options for assistance. Since creating a staff messaging the EHR for co-pay assistance and foundation payments, pool and financial navigation flyer, we have seen an all payments were bundled into a standard insurance increase in patient interaction with DuPage Medical payment code used by the Payment Post department. Group financial navigators. Without the payment code, use of a spreadsheet was necessary to track payments. If a financial navigator cannot reach the patient by phone, we built a Welcome Letter in the EHR that Our EHR has payment codes for site payments, insur- introduces the financial navigator. When this letter is ance payments, co-pay payments, and several other selected, financial navigators can personalize it with codes for account adjustment. The big question was: their own name and contact information. Our financial Why not create a specific payment code for co-pay assis- navigators are knowledgeable in all aspects of a patient’s tance and foundation payments? We determined that account. They can follow up on insurance denials and a payment code specific to these co-pay and founda- billing questions, set up payment plans, and answer tion payments would be a benefit. From 2015 through patient questions. This provides patients with one point 2017, a spreadsheet showed all the data that had to be of contact for all their billing needs. Other patient letters manually added by our biller to reflect these payments. created directly in the EHR for patients include: Demonstrating revenue through that spreadsheet was • Commercial co-pay card letter. Enrollment very helpful in establishing the need for a separate eligibility and rules for co-pay programs through payment code in the EHR. drug manufacturer(s). • Foundation assistance letter. Requesting income By working with the manager of the payment post information (in the event we cannot contact the department, we created a separate, specific payment patient). code for co-pay and foundation payments, allowing • Radiation oncology letter. Assistance is limited management to report on and track an average of for our radiation patients, but we still want to be $30,000 in payments per week through the EHR. This a resource for any billing questions and assist in data was very exciting, and in February of 2018, the setting up payment arrangements. code was activated in the EHR. By creating this code, • Biller letter. Explains that we have designated a we can justify an additional FTE financial navigator biller to handle claim and explanations of benefits or biller in the future and demonstrate the value in (EOBs) submittal to co-pay/foundation assistance assisting with minimizing out-of-pocket expenses for programs. our cancer patients.

6 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 7 We are still tracking co-pay assistance and foundation GOING FORWARD payments on a spreadsheet just to make sure the process In June 2017 DuPage Medical Group began the process is going smoothly between payment post and our biller, of maximizing its EHR use for financial navigation. but the numbers match. Our goal is to eliminate the From January through June 2018, we have tripled our spreadsheet by the end of 2018, and rely solely on EHR enrollments in patient co-pay assistance and founda- reporting on this specific code. tion assistance programs, and we’ve already exceeded what was collected in co-pay and foundation payments As for billing to co-pay assistance programs and founda- for all of 2017. Our EHR has supported our vision and tions, the biller can fax and upload claims and EOBs for needs, and we are continuing to work with IT and other reimbursement. Follow-up is done via phone or portal, departments to bridge any gaps in communications and based on the setup of the drug manufacturer or foun- workflow processes to provide a better experience for dation. There is a designated work queue for patients the patient. y enrolled into a co-pay or foundation assistance program. Our biller works closely with financial navigators if a Natasha Gomes serves as a team lead financial navigator at re-enrollment needs to be updated. The biller also uses DuPage Medical Group, Downers Grove, Ill. She has two activity codes: one for when the co-pay assistance more than four years of experience with oncology and program or foundation is billed, and another when a infusion financial navigation and has worked within payment is received. The biller always checks to make DuPage Medical Group for 13 years. Gomes graduated sure that the appropriate payment code is being used. from Lewis University with a BS in business administration. Gomes wishes to thank her financial navigation team for their contributions — Celeste, Delorse, Sheria, and Liza.

OUR PROGRAM AT-A-GLANCE

The integrated oncology program at DuPage Medical and is the only CoC-accredited freestanding cancer Group provides comprehensive care for patients with center in Illinois. DuPage Medical Group is staffed by all types of cancer from the time of screening through board-certified physicians that specialize in radiology, diagnosis, treatment, and recovery support. DuPage surgical oncology, urologic oncology, medical oncology, Medical Group has been granted Accreditation with radiation oncology, and plastic surgery who work closely Commendation from the Commission on Cancer (CoC) with dedicated nurse navigators and genetic counselors.

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 7 Flowchart

STEP 1. Provider writes chemotherapy order for patient. STEP 2. Chemotherapy order is sent to finance staff. STEP 3. Staff identifies the patient’s financial status and follows the appropriate flowchart below.

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

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

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

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

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

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

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

8 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 9 Flowchart

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/ create payment that is available. or anything else to plan for any balance help 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.

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 9 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).

RUX-1887_OverviewJrnlAd_ACCC-OncologyIssues_8x10-75_x1a.indd 1 9/22/16 11:19 AM accc-cancer.org/drugdatabase

Association of Community Cancer Centers Oncology Drug Database

Find comprehensive coding, billing, and reimbursement information for every approved oncology drug in a single, easy-to-use location, including information on both provider-administered (Part B) and provider-prescribed (Part D) drugs.

Search for a generic or brand name drug to find information on:

· Billing (HCPCS, NDC) and diagnosis (ICD-9 and ICD-10) codes

· Medicare payment limits (does not include the reduction due to sequestration)

· Reimbursement amounts

· FDA-approved indications

· Drug manufacturer information, including contact information for the medical affairs department and reimbursement specialists

For more information, visit accc-cancer.org/drugdatabase Questions on how to use the ACCC Oncology Drug Database? Email [email protected].

Reimbursement Made Easy

Brought to you by

PAP.drugdatabasead.8x10.75.indd 1 4/22/19 5:42 PM ASSOCIATION OF COMMUNITY CANCER CENTERS

IMMUNO- ONCOLOGY INSTITUTE

As immunotherapy for cancer continues to evolve, ACCC adapts to meet the changing needs of the oncology community.

The ACCC Immuno-Oncology Institute is the only initiative dedicated to educating multidisciplinary teams to go beyond a clinical understanding of IO and tackle real-world implementation issues.

With the care of patients on immunotherapies now extending beyond the cancer team, the ACCC Immuno-Oncology Institute is at the forefront of developing critical education to empower healthcare professionals across care delivery settings.

Access resources at the intersection of science, business, operations, and policy to support all facets of immunotherapy integration at accc-cancer.org/immunotherapy

The Association of Community Cancer Centers (ACCC) is the leading education and advocacy organization for the multidisciplinary cancer team. ACCC is a powerful network of 24,000 cancer care professionals from 2,100 hospitals and practices nationwide. ACCC is recognized as the premier provider of resources for the entire oncology care team. For more information, visit accc-cancer.org or call 301.984.9496. Follow us on Facebook, Twitter, and LinkedIn, and read our blog, ACCCBuzz.

The ACCC Immuno-Oncology Institute is the leader in optimizing the delivery of cancer immunotherapies for patients by providing clinical education, advocacy, research, and practice management solutions for cancer care teams across all healthcare settings.

The ACCC Immuno-Oncology Institute is supported by Bristol-Myers Squibb (charitable donation); EMD Serono; Kite, a Gilead Company; and Merck & Co, Inc. (educational grant). AbbVie

AbbVie, Inc.

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

Patient and Reimbursement Assistance Website abbvie.com/patients/patient-assistance.html

PATIENT ASSISTANCE To apply, complete the Patient Assistance Application (abbvie.com/ AbbVie Patient content/dam/abbvie-dotcom/uploads/ Assistance Foundation PDFs/pap/Lupron-Application- The AbbVie Patient Assistance Foun- approved.pdf) and mail to the dation provides AbbVie medicines AbbVie Patient Assistance Foun- at no cost to eligible patients dation or fax to 1.866.483.1305. experiencing financial difficulties. Upon review of a completed appli- AbbVie reviews all applications on cation, AbbVie will notify the a case-by-case basis to support the prescriber and patient about eligi- AbbVie Patient Assistance Founda- bility. If approved, AbbVie will ship tion’s purpose of providing products the medication to the prescriber’s at no cost to individuals in need. office. Patient or prescriber can call Participation in the program is free; 1.800.222.6885 to request a refill or AbbVie does not collect any fees request additional assistance. from people seeking their assistance. REIMBURSEMENT Eligibility criteria include: ASSISTANCE • You must live in the United States. • You are being treated by a licensed Reimbursement Resource U.S. health care provider on an If you are having issues with outpatient basis and prescribed an reimbursement of your Lupron AbbVie medication. Depot purchases, call the • You have no health insurance toll-free reimbursement hotline at or have limited insurance 1.800.453.8438. coverage (including Medicare) for an AbbVie medicine and meet financial criteria based on household income and out-of-pocket medical expenses.

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 13 Amgen

Amgen, Inc.

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

Patient and Reimbursement Assistance Websites amgenassist360.com amgenfirststep.com

government-funded healthcare is responsible for costs above these PATIENT ASSISTANCE program, such as Medicare, amounts. Co-pay Assistance Medicare Advantage, Medicare Support Part D, Medicaid, Medigap, VA, Restrictions may apply. Amgen Amgen offers co-pay coupon DoD, or TRICARE. reserves the right to revise or programs for Blincyto, Imlygic, • Patients may not seek reim- terminate this program, in whole Kyprolis, Neulasta, Neupogen, bursement for value received or in part, without notice at any Nplate, Prolia, Vectibix, and Xgeva from the Amgen FIRST STEP time. This is not health insurance. to help eligible patients who are Program from any third-party Program invalid where otherwise commercially insured with their payers, including flexible spending prohibited by law. Register before deductible, co-insurance, and/or accounts or healthcare savings any Amgen treatment. co-payment requirements. To accounts. confirm patient eligibility and Learn more at the Amgen FIRST enroll in one of these programs, Coverage Limits STEP Co-pay Card Program Health call 1.888.65.STEP1 (888.657.8371) • Program covers out-of-pocket Care Provider Portal: https://amgen or visit amgenfirststep.com. medication costs for the Amgen firststep.com/hcp. From the portal, product only. Program does not healthcare providers can enroll Amgen FIRST STEP™ cover any other costs related to patients, review records, download Program office visit or administration of the forms, and upload documents. This financial support program Amgen product. Other restrictions Questions? Call 1.888.65.STEP1 helps commercially-insured eligible may apply. (1.888.657.8371) Monday through patients with their co-pay and other • No out-of-pocket cost for first Friday, 9:00 am to 8:00 pm ET. treatment costs. Patient eligibility dose or cycle; $5 out-of-pocket requirements: cost for subsequent dose or cycle. Uninsured Patients • Patients must be prescribed one of Maximum benefit of $10,000 per Patients may be able to receive the drugs listed above. patient per calendar year. (For Amgen medications at no cost from • Patients must have private Kyprolis: maximum benefit of Amgen Safety Net Foundation commercial health insurance that $20,000 per patient per calendar (amgensafetynetfoundation.com) if covers medication costs for the year; for Prolia: $25 out-of-pocket they meet the following requirements: drugs listed above. for subsequenct dose or cycle, • Have lived in the U.S. or its terri- • Patients must not participate maximum benefit of $1,500 per tories for six months or longer in any federal, state, or patient per calendar year.) Patient • Satisfy income eligibility requirements

14 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 15 Amgen

• Are uninsured or their insurance can stay focused on their treatment. sional is solely responsible for plan excludes the Amgen Nurse Ambassadors are there to determining coverage, coding, medicine. support, not replace, treatment plans and reimbursement. Amgen does and do not provide medical advice not guarantee coverage or reim- Certain Medicare Part D patients or case management services. bursement. Visit amgenassist360. with product coverage who cannot They can: com/hcp/patient-support/amgen- afford their out of pocket costs may • Help patients with insurance access-specialist for more. be eligible. It is required that they benefit verification and put them are able to demonstrate: in touch with programs that may At the Benefit Verification Center, • Inability to afford the medicine help them afford their prescribed providers can electronically submit, • Ineligibility for Medicaid or medication store, and retrieve benefit verifica- Medicare’s low-income subsidy • Refer patients to independent tions for all patients currently on (Extra Help) nonprofit organizations that may an Amgen product or determine • Have satisfied all payer guidelines provide assistance with treat- regional coverage specifics with and Prior Authorization (PA) ment-related travel costs such as the Local Payer Wizard tool. They requirements prior to applying gas, tolls, parking, airfare, and can assist with benefit verification for assistance lodging support, including sending a • Do not have any other financial • Help patients get in touch with summary of benefit letters, prior support options. independent nonprofit organiza- authorization details, and follow-up tions that may provide community appeals assistance. To register your To apply, visit amgensafetynet resources, local support groups, practice, visit amgenassistonline.com. foundation.com/how-to-apply.html, and counseling services. select the appropriate medication, complete the Patient Application, For more, call 1.888.4ASSIST and fax the completed appli- (1.888.427.7478), Monday through cation and prescription form to Friday, 9:00 am to 8:00 pm ET. 1.866.549.7239. REIMBURSEMENT Once a completed application and ASSISTANCE any requested supporting documents have been received and processed, Amgen Assist 360™ the patient and provider will be Connect with an Amgen Reim- notified of the enrollment decision. bursement Counselor by phone or Missing information or an incom- schedule a visit with a Field Reim- plete application will delay an bursement Counselor by phone enrollment decision. Eligible patients or schedule a visit with a Field are enrolled for a period up to 12 Reimbursement Specialist to receive months. To re-enroll in Amgen Amgen product reimbursement assis- Safety Net Foundation, patients tance with the following: must submit a new application. • Insurance verifications • Prior authorizations Questions? Contact 1.888.762.6436, • Billing and claims support and Monday through Friday, 9:00 am to updates 8:00 pm ET. • Local payer information

Amgen Assist 360™ Amgen provides information Amgen Assist 360™ Nurse Ambas- as a courtesy only. It is not sadors are there to support your intended to be comprehensive or treatment plan and help patients and instructive. Coding and coverage caregivers find the resources that are policies can change without most important to them so that they warning. The healthcare profes-

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 15 Array Biopharma

Array BioPharma

Oncology-related products: Braftovi® (encorafenib) capsules, Mektovi® (binimetinib) tablets

Patient and Reimbursement Assistance Website braftovimektovi.com/hcp/financial-support/

PATIENT ASSISTANCE Array Patient Assistance • Benefits investigation and Program verification Array ACTS™ Under- and underinsured patients • Prior authorizations and appeals Array is committed to helping may be eligible for free medicine support. patients access its medicines, provided through the Array Patient regardless of their insurance Assistance Program. To be eligible To enroll in Array ACTS, coverage. Array can assist in for this program, insured patients download the enrollment form providing financial support to: must have exhausted all other (braftovimektovi.com/assets/pdfs/ • Commercially insured patients forms of patient assistance and array_acts_enrollment_form.pdf) • Government-insured patients meet financial criteria. Insured and and fax the enrollment form • Under- and uninsured patients. uninsured patients must also meet and prescription separately to certain eligibility criteria. Call 1.866. 1.877.299.9226. An Array ACTS To enroll in Array ACTS, ARRAYCS (1.866.277.2927) for case manager will contact you upon download the enrollment form more information. receipt of a completed application. (braftovimektovi.com/assets/pdfs/ Patients and healthcare providers array_acts_enrollment_form.pdf) Independent Co-pay are responsible for completing and fax the enrollment form Assistance Foundations and submitting enrollment forms and prescription separately to Array ACTS can provide referrals to and coverage or reimbursement 1.877.299.9226. An Array ACTS independent co-pay assistance foun- documentation. Array makes no rep- case manager will contact you upon dations for eligible patients who are resentation or guarantee concerning receipt of a completed application. commercially or government-insured. coverage or reimbursement of any Array does not influence or control service or item. Array Co-Pay Savings Program the operations or eligibility criteria Eligible commercially insured patients of any independent co-pay assistance For more information on Array may pay as little as $0 per month foundation and cannot guarantee ACTS and all available assis- supply of Braftovi + Mektovi. To co-pay assistance after a referral. tance programs, please call 1.866. activate the Co-Pay Savings Program, There may be other foundations to ARRAYCS (1.866.277.2927). visit qv.trialcard.com/array and begin support the patient’s disease state. the enrollment process. In order to be eligible for the Array Co-Pay Savings REIMBURSEMENT Program, the patient must not have ASSISTANCE government-funded health insurance (e.g., Medicare, Medicaid, or any Array ACTS™ other federal or state program) and Array ACTS provides a range of must be taking Braftovi + Mektovi support services to help eligible for an FDA-approved indication. patients, including:

16 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 17 Astellas

Astellas Pharma US, Inc.

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

Patient and Reimbursement Assistance Website astellaspharmasupportsolutions.com

PATIENT ASSISTANCE patients who experience an insur- The Program is not valid for patients ance-related delay. To be eligible, whose prescription claims are Astellas Pharma Support patients must: reimbursed, in whole or in part, SolutionsSM • Have prescription drug insurance by any state or federal government Astellas Pharma Support Solutions • Be new to Xospata therapy program, including but not limited offers access and reimbursement • Have been prescribed Xospata for to Medicaid, Medicare, Medigap, support to help patients and their an FDA-approved indication Department of Defense (DoD), healthcare providers overcome • Have experienced an insurance-re- Veterans Affairs (VA), TRICARE, challenges to accessing Astellas lated access delay. Puerto Rico Government Insurance, products. To enroll in either Xospata or any state patient or pharmaceu- Support Solutions or Xtandi Support To enroll, fill out the appropriate tical assistance program. Solutions, visit astellaspharmasupport section during the Xospata Support solutions.com, select the appropriate Solutions enrollment process. Xtandi Support SolutionsSM medication, and follow the patient Xtandi Support Solutions (astellas enrollment process. Xospata Copay Card Program pharmasupportsolutions.com/ The Xospata Copay Card Program products/xtandi/index.aspx) offers Xospata Support SolutionsSM is for eligible patients who have access and reimbursement services Xospata Support Solutions (astellas commercial prescription insurance. to help patients and providers pharmasupportsolutions.com/ The Program parameters are as overcome challenges to accessing products/xospata/index.aspx) offers follows: Xtandi. It provides information access and reimbursement support • Patients pay as little as $0 per regarding patient healthcare to help patients access Xospata. prescription coverage options and financial It provides information regarding • A patient will be enrolled in the assistance programs to help patients patient healthcare coverage options Program for a 12-month period with financial needs. To speak and financial assistance information • The Program benefit covers up with a dedicated access specialist, that may be available to help to a maximum of $25,000 per please call 1.855.8XTANDI patients with financial needs. To calendar year (1.855.898.2634), Monday through speak with a dedicated access spe- • There are no income requirements. Friday, 8:00 am to 8:00 pm ET. cialist, call 1.844.632.9272, Monday through Friday, 8:30 am to 8:00 pm Xospata Support Solutions can Xtandi Quick Start+™ Program ET. evaluate eligibility and enroll The Xtandi Quick Start+ Program patients in the Xospata Copay Card provides a free, one-time, 14-day Xospata Quick Start+® Program Program, or the preferred network supply of Xtandi to new patients The Xospata Quick Start+ Program specialty pharmacy can be contacted who experience a delay in insurance provides a one-time, 7-day supply to determine eligibility and enroll the coverage. Overnight shipping is of Xospata at no cost to eligible patient in the Program. offered directly to the patient. In

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 17 Astellas

order to be eligible for the Quick Part D, Medigap, DoD, VA, • Requirements for prior authori- Start+ program, patients need to: TRICARE, Puerto Rico Government zation, step edit, or other coverage • Have prescription drug insurance Insurance, or any state patient or restrictions, if any • Be new to Xtandi therapy pharmaceutical assistance program. • Cost-sharing responsibility, • Have experienced an insurance-re- including deductibles, coinsurance lated access delay Astellas Patient Assistance or copayment, and out-of-pocket • Have been prescribed Xtandi for Program maximums an FDA-approved indication. The Astellas Patient Assistance • A list of specialty pharmacies Program provides Xtandi and that participate in your patient's Xtandi Quick Start+ Program allows Xospata at no cost to patients who insurance coverage. your patient to start their Xtandi meet the program treatment while Xtandi Support Upon completion of the specific Solutions or a network specialty eligibility requirements. The patient drug’s patient enrollment process, pharmacy works with the patient’s may be eligible if they meet the the benefits verification process insurer to resolve coverage issues. following criteria: begins. Once it is complete, a To enroll, fill out the appropriate • Patient is uninsured or has summary of benefits will be sent. section during the Xtandi Support insurance that excludes coverage Solutions enrollment process. for Xtandi or Xospata Prior Authorization • Patient has a verifiable shipping Astellas Pharma Support Solutions Xtandi Patient Savings Program address in the United States can provide prior authorization (PA) The Xtandi Patient Savings Program • Patient has been prescribed Xtandi assistance when a patient’s insurer is for eligible patients who have or Xospata for an FDA-approved requires PA approval. Prior authori- commercial prescription insurance. indication zations will be communicated to the The program parameters are as • Patient meets program financial patient and provider and the pre- follows: eligibility requirements. scription will be sent to a specialty • Patients can pay as little as $0 per pharmacy. Xtandi or Xospata prescription To enroll a patient in the Astellas Support Solutions will follow up • Co-pay assistance is available for Patient Assistance Program, with the specialty pharmacy to up to 12 refills during a 12-month complete the Xtandi or Xospata confirm receipt and check status and period after enrollment (the Support Solutions enrollment notify of the outcome. “Enrollment Period”) process. If the patient is eligible, the • The program covers up to a patient and provider will be notified, If the patient’s insurance denies a maximum of $25,000 during an and the prescription will be shipped prior authorization request, Xtandi Enrollment Period directly to the patient's home. or Xospata Support Solutions • There are no income requirements. can assist the healthcare provider REIMBURSEMENT with an appeal for a denied PA Patients must provide their Savings ASSISTANCE request. Xtandi or Xospata Support Card ID number to the specialty Solutions will determine if any pharmacy when they fill their pre- Astellas Pharma Support additional documentation is required scription. There are 2 ways patients SolutionsSM by the patient’s insurer, inform can receive the Savings Card: by Benefits Verification the healthcare provider of what contacting their specialty pharmacy Astellas Pharma Support Solutions information is needed and how to or by applying for the Savings Card offers benefits verification assistance provide it to the insurer, and track at activatethecard.com/xtandi. to evaluate a patient’s insurance and inform the healthcare provider coverage for Xtandi and Xospata. of the appeal status. The program is not available to After performing a benefits verifi- patients who have prescription cation, a summary of benefits will be drug coverage paid in part or in full provided that includes: under any state or federally-funded • The patient's insurance coverage programs, including but not limited requirements for the medication to Medicaid, Medicare, Medicare

18 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 19 AstraZeneca

AstraZeneca

Products: Calquence® (acalabrutinib) capsules, Faslodex® (fulvestrant) injection, Imfinzi® (durvalumab) injection, Iressa® (gefitinib) tablets, LumoxitiTM (moxetumomab pasudotox-tdfk,) Lynparza® (olaparib) tablets and capsules, Tagrisso® (osimertinib) tablets

Patient and Reimbursement Assistance Websites astrazenecaspecialtysavings.com MyAccess360.com

PATIENT ASSISTANCE 3. A Patient Savings Program • Pharmacy coordination account will be created for the • Reimbursement process AstraZeneca has a commitment to eligible patient. Once enrolled, • Denial and appeal support providing affordable access to its patient-specific account infor- • Providing eligibility requirement medications and wants to ensure mation will be presented in the information and enrollment that cost is not a barrier when a portal for immediate use. assistance for specialty Patient physician has determined that an 4. The patient will pay a set amount of Savings Programs AstraZeneca medication is appro- his or her out-of-pocket costs, based • Referring patients to patient priate for a patient. on the product. The pharmacy or assistance programs provider will use the Patient Savings • Connecting to nurse assistance or Patient Savings Programs for Program to cover the balance, up to educational support programs, if Calquence, Faslodex, Imfinzi, Iressa, the program maximum. applicable (not for all medicines). Lumoxiti, Lynparza, and Tagrisso help eligible commercially insured For more information about eligi- To learn more about the Astra- patients with the out-of-pocket costs bility and details on these programs, Zeneca Access 360 program, call of their prescriptions. Patients please visit astrazenecaspecialty 1.844.ASK.A360 (1.844.275.2360), enrolled in government-funded savings.com or call AstraZeneca Monday through Friday, 8:00 am to healthcare programs such as Access 360 at 1.844.ASK.A360 8:00 pm ET to speak with a knowl- Medicare, Medicaid, Medigap, (1.844.275.2360). edgeable member of the team or Veterans Affairs (VA), or TRICARE visit www.MyAccess360.com. are not eligible for AstraZeneca’s AstraZeneca Access 360™ patient savings programs. Program The AZ&Me™ Prescriptions The AstraZeneca Access 360™ Savings Programs How the Programs Work: program provides personal support The AZ&Me™ Prescriptions Savings 1. Your patient may have an to connect patients to affordability Programs are designed to help qual- out-of-pocket cost for an programs and streamline access and ifying people without insurance and AstraZeneca treatment. reimbursement for AstraZeneca’s those in Medicare Part D who are 2. If the patient meets the eligibility medicines. Our reimbursement coun- still having trouble affording their requirements, you can enroll him selors help patients and providers AstraZeneca medications. There are or her into the Patient Savings with: two programs: Program via the online enrollment • Identifying and understanding pre- • AZ&Me Prescription Savings portal. The links to the portal for scription coverage, out-of-pocket program for people without each product can be found at costs, and pharmacy options insurance astrazenecaspecialtysavings.com. • Prior authorization support

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 19 AstraZeneca

• AZ&Me Prescription Savings • Patient must not be eligible for • Patient must have spent 3% or program for people with Medicare Medicaid in their state of residence. more of total household income Part D. on prescription medicines through Application Checklist a Medicare Part D Prescription There is a shared application The following items must be Drug Plan during the current year process for the AZ&Me Pre- submitted in order to complete • Patient must not be eligible for LIS scription Savings program for enrollment in the program: (“extra help”) people without insurance and • A completed application signed • Patient must be a legal U.S. the AZ&Me Prescription Savings and dated by the patient and resident program for people with Medicare prescriber • Patient must not be eligible for Part D, and the same application is • A completed prescription Medicaid in their state of residence used for both programs. To apply (included on page 3 of the • Patients with Medicare Part B for the program you may either call application) coverage may also be eligible. 1.800.AZandMe (1.800.292.6363) • Proof of household income. Please call 1.800.AZandMe or visit azandmeapp.com to (1.800.292.6363) for more download an application. For an Please note that faxed applications information. updated list of the medications must be sent from a physician’s available through the AZ&Me office in order for their prescription Application Checklist Prescription Savings Program, to be processed. The following items must be please visit azandmeapp.com. submitted in order to complete For more information, please visit enrollment in the program: Patients without azandmeapp.com or call 1.800. • A completed application signed Insurance AZandMe. and dated by the patient and prescriber Program Highlights Patients with Medicare • A completed prescription • AstraZeneca medicines provided Part D (included on page 3 of the at no cost application) • Medicines mailed to patient’s Program Highlights • Proof of household income home or physician’s office • AstraZeneca medicines provided • A copy of the front and back of • Up to 30 days of product provided at no cost the patient’s Medicare Part D for each fill • Medicines mailed to patient’s Plan Card • Qualified patients provided with home or physician’s office • A copy of the patient’s Medicare temporary enrollment and medi- • Up to 30 days of product provided Part D Prescription Drug Plan cation supply while application is for each fill statement (Explanation of being processed • Qualified patients provided with Benefits [EOB]), a pharmacy • Applications accepted via phone, temporary enrollment and medi- printout, or a summary fax, or mail cation supply while application is document from a pharmacy • Annual enrollment; patients being processed indicating the amount spent may re-enroll after 12 months if • Applications accepted via phone, on prescriptions in the current eligible. fax, or mail calendar year; this total should • Enrollment is by calendar year; be at least 3% of the patient’s Eligibility Requirements patients are enrolled until 12/31 of total household income. • Patient must be without pre- the current year and may re-enroll scription drug coverage through if eligible. Please note that faxed applications private insurance or government must be sent from a physician’s programs Eligibility Requirements office in order for their prescription • Patient must have annual gross • Patient must be enrolled in a to be processed. household income at or below a Medicare Part D Plan certain level • Patient must have annual gross For more information, please visit • Patient must be a legal U.S. household income at or below azandmeapp.com or call resident a certain level 1.800.AZandMe.

20 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 21 Bayer HealthCare

Bayer HealthCare Pharmaceuticals, Inc.

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

Patient and Reimbursement Assistance Websites hcp.xofigo-us.com/patient-financial-assistance zerocopaysupport.com hcp.aliqopa-us.com/access-and-reimbursement/arc-program/

PATIENT ASSISTANCE Registered users can also submit with Xofigo are not eligible for an application for patient assis- copay assistance through the Xofigo Xofigo Access Services tance via the secure Xofigo Access Access Services commercial copay/ Uninsured Patients Services Provider Portal: xofigo coinsurance assistance program. If Xofigo Access Services may provide accessonline.com. your patient needs assistance with Xofigo free of charge for eligible cost-share requirements, they may patients who are uninsured or who $0 Commercial Copay be eligible for copay or coinsurance are insured but do not have coverage Assistance Program assistance through an independent for Xofigo. You must apply for Your patient may be eligible for copay/coinsurance assistance assistance on your patient’s behalf copayment/coinsurance assistance foundation. Xofigo Access Services by submitting a completed appli- if your patient has a private com- Access Counselors can verify your cation, including a signed patient mercial plan that covers Xofigo. patients’ coverage for Xofigo and authorization. Visit https://hcp. Patients approved for assistance will provide information about any xofigo-us.com/patient-financial- not have to pay anything to access available foundation. assistance for more information. Xofigo. Eligibility criteria include: Eligibility criteria include: • Patient has private commercial REACH® • Financial criteria based on insurance Patients taking Stivarga or Nexavar adjusted gross household income • Residency in the United States, can enroll in REACH® (Resources (documentation of income is including the District of for Expert Assistance and Care required) Columbia, Puerto Rico, Guam, or Helpline). This free program is here • Residency in the United States, the U.S. Virgin Islands. to support patients and caregivers including the District of with information about therapy Columbia, Puerto Rico, Guam, or To apply, fax a completed patient and financial assistance options. the U.S. Virgin Islands. assistance application including The REACH program offers Nurse the signed patient authorization Counselors to answer medical Fax a completed application, to Xofigo Access Services at questions and provide educational including the signed patient autho- 1.855.963.4463. Once approved, and support materials, as well rization, to 1.855.963.4463. your patient receives an approval as guidance on side effects, and Call an Access Counselor at letter with a commercial copay/coin- Financial Access Counselors to 1.855.6XOFIGO (1.855.696-3446), surance identification (ID) card. provide help with: Monday through Friday, 9:00 • Benefit verification and specialty am to 7:00 pm ET, if you have Medicare beneficiaries and patients pharmacy provider (SPP) any questions or to obtain more with other government insurance identification information. who need help paying for treatment

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 21 Bayer HealthCare

• Patient Assistance Program (PAP) Aliqopa Resource REIMBURSEMENT for the uninsured or underinsured Connections ASSISTANCE • Prior authorizations and denial/ The ARC Patient Support Program appeal information offers comprehensive access, reim- Xofigo Access Services • Co-pay assistance for eligible bursement support, and patient Xofigo Access Services provides commercially insured patients not assistance services: comprehensive reimbursement previously enrolled in the REACH • The Bayer Patient Assistance assistance, including: Commercial Co-Pay Assistance Program provides Aliqopa free of • Insurance benefit verifications Program charge for eligible patients who • Prior authorization support • Alternative coverage research are uninsured or underinsured. • Claims appeal research and • Referral to independent organi- In order to qualify for assistance, information zations that may assist eligible patients must meet certain eligi- • Claims tracking patients with their out-of-pocket bility criteria. • Billing and coding information expenses. • The Temporary Patient Assis- • Payer policy information. tance Program is for patients Visit nexavar-us.com/co-pay- whose coverage is delayed or who To access these services, call assistance/ for more information. experience a temporary lapse in 1.855.6XOFIGO (1.855.696.3446) coverage for Aliqopa. 9:00 am to 7:00 pm ET, Monday Privately Insured Patients • The Aliqopa $0 Co-Pay Program through Friday. You can also access • No monthly cap is for eligible patients with com- these services online 24/7 through • Up to $25,000 per year mercial insurance. Patients must the Xofigo Access Services Provider • Enroll at: zerocopaysupport.com not be enrolled in a govern- Portal: xofigoaccessonline.com. • Obtain BIN & Group # and ment-sponsored program and provide to your pharmacist. must meet certain other eligibility REACH® criteria to qualify for this program. Some insurance plans require Call 1.866.581.4992 for more If approved, the patient may pay patients to obtain approval for information on enrolling online. as little as $0, with a maximum coverage before starting therapy benefit of $25,000 per year. (known as Prior Authorization), Government Insured • Referrals to independent assistance which can take time and delay the • Information on Part D foundations for publicly insured start of therapy. REACH may be prescription drug plans patients and those requiring travel able to provide temporary assistance • Financial assistance may be assistance may be provided. for patients to start therapy right available through independent away while waiting for their Prior charitable organizations. For more information, visit Authorization approval. hcp.aliqopa-us.com/access-and- Call 1.866.639.2827 to speak with reimbursement/arc-program/ or Visit www.nexavar-us.com/ a reimbursement counselor (9:00 am call an Access Counselor at 833. reach-financial-support/ for more to 5:00 pm ET). ALIQOPA (833.254.7672), Monday information. through Friday, 9:00 am to 7:00 pm. Uninsured/Underinsured The REACH program has Nurse • Patient Assistance Program (PAP) Counselors to answer medical • Eligibility requirements apply questions and provide educational • Up to 12 months of free drug for and support materials, as well qualified patients. as guidance on side effects, and Financial Access Counselors to Call 1.866.639.2827 to speak with provide help with: a reimbursement counselor (9:00 am • Benefit verification and specialty to 5:00 pm ET). pharmacy provider (SPP) identification • Patient Assistance Program (PAP) for the uninsured or underinsured

22 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 23 Bayer HealthCare

• Prior authorizations and denial/ appeal information • Co-pay assistance for eligible commercially insured patients not previously enrolled in the REACH Commercial Co-Pay Assistance Program • Alternative coverage research • Referral to independent organizations that may assist eligible patients with their out-of-pocket expenses.

Aliqopa Resource Connections The ARC program provides support for prescribers, office staff, patients, and caregivers through the access and reimbursement process. Access Counselors are available to provide the following support services: • Insurance benefit verifications • Prior authorization information (physician office must submit prior authorization) • Claims appeal information • Claims status • Billing and coding information • Payer policy information.

For more information, call 833. ALIQOPA (833.254.7672), Monday through Friday, 9:00 am to 7:00 pm ET, or visit hcp.aliqopa-us. com/access-and-reimbursement/ arc-program/.

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 23 Boehringer Ingelheim

Boehringer Ingelheim Pharmaceuticals, Inc.

Oncology-related product: Gilotrif® (afatinib)

Patient and Reimbursement Assistance Website patientservices.gilotrifhcp.com

PATIENT ASSISTANCE cost is no more than $0 per month have 9 or more tablets to exchange. (subject to a maximum monthly Dispensing pharmacies can call Gilotrif Patient Services benefit of $5,500 and a maximum 1.877.814.3915 to learn more. Provided by Accredo for annual benefit of $25,000) for Non-dispensing accounts can call non-dispensing accounts and commercially insured U.S. resident 1.844.569.2836 to learn more. Solutions Plus for dispensing patients. No income eligibility or accounts, Gilotrif Patient Services additional paperwork is required. The Boehringer Ingelheim offers a range of services to help Cares Foundation Patient alleviate financial concerns around Bridge Program Assistance Program access for Gilotrif. Insurance coverage Eligible patients experiencing more The Boehringer Ingelheim Cares should not be a barrier to cancer than a 5-day payer approval delay Foundation Patient Assistance treatment—we will explore multiple can receive a 15-day supply of Program helps those in need obtain options to help a variety of patients Gilotrif at no cost to the patient medications free of charge, including afford their treatment. for the FDA-approved indications. senior citizens and families with Gilotrif Patient Services ensures the limited incomes. To learn more, call Non-dispensing accounts can enroll maximum out-of-pocket cost is no 1.800.556.8317, Monday through in Accredo by calling 844.569.2836 more than $0 per month (subject Friday, 8:30 am to 6:00 pm ET. or by downloading the prescription to a maximum monthly benefit of Patients wishing to be considered for and enrollment form at patientser- $5,500 and a maximum annual eligibility must submit a completed vices.gilotrifhcp.com/sites/default/ benefit of $25,000) for commercially application (found at boehringer- files/accredo_prescription_and_ insured U.S. resident patients. ingelheim.us/sites/us/files/files/ enrollment_form.pdf. Fax the gilotrif-pap-application.pdf) completed form to 888.454.8488. Gilotrif Dose Exchange™ along with: Gilotrif Dose Exchange facilitates • Proof of income Dispensing pharmacies can apply the transition to a new dose at no • Original valid prescription with to Solutions Plus by calling cost while eliminating an additional physician signature 1.877.814.3915, 8:30 am to 6:00 Gilotrif co-pay in a given month for • Any other applicable pm ET or by downloading the appli- eligible patients. Eligible patients documentation. cation at patientservices.gilotrifhcp. receive a new dose of Gilotrif with com/sites/default/files/solutions_ convenient packaging to return Fax the documents to 1.866.240.4556. plus_enrollment_form.pdf. Fax the unused tablets. Only faxes sent from the prescribing completed form to 1.866.240.4556. physician’s office along with physi- Gilotrif Dose Exchange covers up cian’s fax cover sheet and fax banner Co-pay Assistance Program to 2 dose modifications for patients can be accepted. The Co-pay Assistance Program serviced through Accredo or the ensures the maximum out-of-pocket Gilotrif Dispensing Network who

24 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 25 Boehringer Ingelheim

REIMBURSEMENT ASSISTANCE Communication Skills 101 Gilotrif Patient Services Effective communication is a two-way process involving listening and Coverage and speaking. It is a learned skill that requires practice. Listening and speaking Access Assistance are equally important to the process. To listen effectively, you must resist Upon receipt of the Gilotrif Patient formulating your response while the other person is still speaking. The better Services enrollment form, patient option: allow a thoughtful pause while you both digest what has been said. specialists investigate and verify coverage for patients within 2 Tips for Effective Speaking business days. Patient specialists • Pay attention—not just to your words, but also to your non-verbal communicate prior authorization message(s). requirements for payers and assist with the reimbursement process. • Putting a desk between you and the patient and family can foster a perception of distance. If possible, position yourself at a 35 to 45 degree For dispensing pharmacies, Boehringer angle towards the patient and keep your arms relaxed and open towards Ingelheim Reimbursement and their body. Access Managers provide appeals support upon prior authorization • Try not to look tense or stressed, instead adopt a relaxed and calm denial, help facilitate requests demeanor. Look up frequently to maintain eye contact. for additional information from Boehringer Ingelheim, and provide • DO smile, sit, or stand comfortably. assistance with ordering Patient • Have at least 2 to 3 minutes of discussion with the patient and family Support Kits. before you begin to take notes. Never “doodle.” Shuffle papers as little as possible. The patient must feel that your focus is on him or her and what they are saying.

• Allow patients and families to see your notes before the end of your visit. Remember: transparency builds trust.

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

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 25 Bristol-Myers Squibb

Bristol-Myers Squibb

Oncology-related products: Empliciti® (elotuzumab), Opdivo® (nivolumab), Sprycel® (dasatinib), Yervoy® (ipilimumab)

Patient and Reimbursement Assistance Website bmsaccesssupport.com

PATIENT ASSISTANCE Final determination of program questions or to confirm receipt of the eligibility is based upon review of application, call the Support Center BMS Access Support® completed application. Note: Absent at 1.800.861.0048, 8:00 am to 8:00 Bristol-Myers Squibb (BMS) Access a change in Massachusetts law, pm ET, Monday through Friday. Support can help identify financial effective July 1, 2019, Massachusetts assistance programs for eligible residents will no longer be able to Assistance for patients who need help managing participate in this program. Uninsured Patients the cost of treatment. The appro- For patients without prescription priate program will depend on the Enrollment is simple. The provider drug insurance, or for patients patient’s coverage. completes the application through who are underinsured, BMS Access BMS Access Support in one of the Support can refer them to inde- BMS Oncology following ways: pendent charitable foundations that Co-Pay Assistance • Download the enrollment form may be able to provide financial Program on your computer and fax to support, including the Bristol-Myers This program is designed to assist 1.888.776.2370. Squibb Patient Assistance Foun- with out-of-pocket co-pay, • Enroll online with our secure portal: dation (BMSPAF): bmspaf.org. This deductible, or co-insurance costs MyBMSCases.com. charitable organization provides for eligible commercially insured medicine, free of charge, to eligible, patients who have been prescribed When completing the form, check uninsured patients who have an certain BMS products. Patients with the box for the BMS Oncology established financial hardship. state or federally-funded insurance Co-Pay Program. BMS Access plans are not eligible for this co-pay Support determines patient eligi- The BMSPAF accepts the BMS program. Enrolled patients pay the bility, including verifying commercial Access Support application. Patients first $25 of their co-pay per infusion. insurance coverage to establish the may be eligible for assistance If the patient receives two BMS appropriate benefit amount. BMS through the BMSPAF if they: medications covered by this program Access Support then notifies the • Do not have insurance coverage on the same day, the combination provider and patient of enrollment for applicable medication of those two medications will be and the appropriate next steps. • Live in the United States, Puerto treated as one dose, requiring the Finally, the provider submits the Rico, or U.S. Virgin Islands patient pay only $25 of the medi- primary claim to the commercial • Are being treated by a U.S.-licensed cations’ co-pay for that day. BMS insurance carrier. If the Explanation physician as an outpatient will cover the remaining amount up of Benefits form indicates that your • Have a yearly income that is at to $25,000 per year per product, patient has a cost-sharing expense, or below 300% of the Federal or $50,000 per year for two BMS notify BMS Access Support and Poverty Level. Medications that are products administered in combi- submit the required documentation injected and certain medications nation. Other restrictions may apply. to initiate appropriate next steps. For may be subject to higher limits.

26 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 27 Bristol-Myers Squibb

These are just some of the eligi- Prior Authorization bility requirements. Other eligibility A Prior Authorization (PA) is a veri- criteria may apply. For more infor- fication from your doctor that states mation about eligibility and to that your medication is medically obtain an enrollment application, necessary. Your insurance company call the Bristol-Myers Squibb may require a PA before they will Patient Assistance Foundation at cover certain medications. BMS 1.800.736.0003. Access Support can provide information about this requirement. Assistance for Patients A PA is not necessary in all cases. with Federally-Funded Insurance Plans Claims Appeals Patients with federally-funded If the patient’s insurer has denied insurance plans are not eligible coverage, BMS Access Support may for co-pay assistance programs be able to assist by providing infor- sponsored by Bristol-Myers Squibb. mation about the appeals process. It However, there are independent is important to review the insurer’s foundations that can help. BMS guidelines and for the patient or Access Support can refer providers provider to submit the required to the foundation offering the best documents and information before support for their specific patient and the appeal deadline. help them through the application process. It is important to note that To start a benefits review or schedule these foundations are independent a call with a care coordinator, visit and not affiliated with Bristol-Myers bmsaccesssupport.bmscustomer Squibb. Each foundation has its connect.com/overview-services. own eligibility criteria and evalu- ation process. Bristol-Myers Squibb cannot guarantee that a patient will receive assistance. For details, contact BMS Access Support at 1.800.861.0048.

REIMBURSEMENT ASSISTANCE BMS Access Support Benefits Verification BMS Access Support can conduct a benefits review. This will typically determine what is covered by the patient’s insurance plan, whether there are any restrictions, and how much money the patient may have to pay to get their medication. A benefits review will identify whether prior authorization is required. For enrolled patients, benefits may also be reverified.

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 27 Celgene Oncology

Celgene Oncology

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

Patient and Reimbursement Assistance Website celgenepatientsupport.com

PATIENT ASSISTANCE • Other eligibility requirements Financial and medical eligibility and restrictions apply. Please see requirements vary by organization. Celgene Patient Support® provides: full Terms and Conditions on the • A single specialist assigned to help Celgene Patient Support® website Transportation Assistance patients in your geographic area (http://media.celgenepatient- Celgene Patient Support® can • Assistance with understanding support.com/wp-content/uploads/ provide information about financial patient insurance coverage for CCCP_Full_Terms_and_ assistance for transportation costs to Celgene medications Conditions.pdf) and from medical appointments. • Information about financial • Independent third-party organiza- assistance for prescribed Celgene Celgene Patient tions may be able to help patients medications. Assistance Program (PAP) with transportation costs, such as The Celgene Patient Assistance gasoline, parking, tolls, and taxi, Celgene Commercial Program is for qualified patients bus, or train fare to and from Co-Pay Program who are uninsured or underinsured. medical appointments. This program is for eligible patients • Celgene medications may be available with commercial or private insurance at no cost to patients who meet Financial and medical eligibility (including healthcare exchanges). insurance and financial criteria requirements vary by organization. • Provides assistance to help patients • Your patients must meet specified meet co-pay/co-insurance costs financial and eligibility require- REIMBURSEMENT • Reduces co-pay responsibility to ments to qualify for assistance. ASSISTANCE $25 or less per prescription with a maximum benefit of $10,000 per Independent At the request of the patient, special- enrollment period. Third-Party Organizations ists are available to assist with For patients who are unable to each of the following steps in the Eligibility criteria for patients include: afford their medication (including insurance approval process for • Commercial or private insurance patients with Medicare, Medicaid, prescribed Celgene medications. that does not cover the full cost of or other government-sponsored Celgene cannot provide insurance the prescribed Celgene medication insurance), Celgene Patient Support® advice or make insurance decisions. • Residence in the United States or a can provide you with information U.S. territory about independent third-party orga- Benefits Investigation • Patients with government nizations that may be able to help • Initiate a benefits investigation to healthcare insurance (for example, patients with the cost of: determine co-payment and other Medicaid, Medicare [Parts B, C, • Deductibles out-of-pocket costs and D], Medigap, and TRICARE • Co-payments/co-insurance • Assess prior authorization or are not eligible) • Insurance premiums. precertification requirements

28 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 29 Celgene Oncology

• Educate patients about insurance celgene.com or fax it to us at coverage or other programs for 1.800.822.2496. which they may qualify.

Prior Authorization/ Precertification Assistance • Assist with the prior authorization or precertification process by providing the necessary forms for completion • Follow up with the insurance provider to determine the outcome • Celgene provides a facilitation service and will not provide any medical input into a prior authorization.

Appeals Assistance • Provide information about the appeals process after a denied prior authorization, precertification, and/or claim • Supply a checklist of the required documentation for submission to the insurance company • Submit the appeal to the insurance company at the request of the patient and follow up on the status until a decision is reached • Celgene provides a facilitation service and will not provide any medical input into an appeal.

Enrolling in Celgene Patient Support® There are three simple ways to enroll in Celgene Patient Support®. Choose the way that is easiest: • Patients can be enrolled in Celgene Patient Support® online at celgenepatientsupport.com • Patients can be enrolled over the phone 1.800.931.8691, Monday to Thursday, 8:00 am to 7:00 pm ET, and Friday, 8:00 am to 6:00 pm ET (translation services available) • Download the English or Spanish enrollment form at celgene patientsupport.com and return it to us by e-mail at patientsupport@

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 29 Coherus BioSciences

Coherus BioSciences

Oncology-related products: Udenyca™ (pegfilgrastim-cbqv)

Patient and Reimbursement Assistance Website coheruscomplete.com

PATIENT ASSISTANCE Part D, Veterans Affairs, the Poverty Level (FPL) Department of Defense, or • Patient must agree to "soft" credit Coherus COMPLETE™ TRICARE check if no required income docu- Coherus COMPLETE provides a • Must not seek reimbursement mentation is provided. suite of patient support services and amount received from Coherus programs designed to assist with from any third-party payers, To enroll, visit login.coherus- patient access. including flexible spending complete.com and follow the accounts or healthcare savings instructions. Coherus COMPLETE Co-Pay accounts. Assistance Program REIMBURSEMENT The Coherus COMPLETE Co-Pay To enroll, visit copay.coheruscomplete. ASSISTANCE Assistance Program provides for com and follow the instructions. $0 out-of-pocket cost for each Coherus COMPLETE™ Udenyca dose. Our program can Patient Assistance Program Coherus COMPLETE can assist help eligible patients who are Udenyca can be provided at no provider offices with benefits veri- commercially insured with out-of- cost to uninsured and underinsured fication. The Coherus COMPLETE pocket costs for Udenyca. Maximum patients with financial hardship Provider Portal (login.coherus- benefit per claim up to $7,200 with through the Patient Assistance complete.com) provides a single maximum annual benefit of $15,000 Program (PAP). Eligibility criteria: repository for all programs with per 12-month enrollment period. streamlined electronic services to Reimbursement arrives via electronic • Uninsured or functionally ease the administrative burden: remit; no physical co-pay card is uninsured required. • U.S. citizen or resident and must • Customized pre-populated data physically reside in the U.S. or a fields To be eligible for the Co-Pay Assis- U.S. territory • Electronic upload of patient tance Program, patients: • Be under the care of a U.S. documentation • Must be prescribed Udenyca for a licensed provider with an estab- • Electronic signatures expedite medically appropriate use lished practice located in the U.S. consents • Must have commercial health • Patients who appear to be • Real-time tracking of approval insurance that covers the medi- Medicaid eligible must have status cation costs of Udenyca received a denial from Medicaid • Fewer errors that delay benefits • Must not be covered by any • Diagnosis and dosing must be • Improves communication with federal, state, or govern- consistent with UDENYCA’s FDA Patient Access Specialists by ment-funded healthcare program approved label providing secure, direct access such as Medicare, Medicaid, • Adjusted annual household Medicare Advantage, Medicare income of ≤ 500% of Federal

30 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 31 Coherus BioSciences

Insurance Benefit Verification • Provides comprehensive product-specific coverage assessments • Determines insurance eligibility based on a patient’s benefit plan and payer policy.

Comprehensive Prior Authorization (PA) Services • Identifies payer AP requirements • Assists in PA submissions • Provides pre-populated payer and pharmacy PA forms when necessary • Tracks PA determinations with payers.

Coding and Billing Support • Provides product-specific coding support • Assists with claims submission questions.

Claims and PA Appeals Support • Provides payer guidance for PA or claims denials • Provides guidance on the appeal submission process • Monitors the appeal request.

Alternative Funding Support • Investigates alternative financial support through independent foundations for eligible patients.

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 31 Eisai

Eisai Co., Ltd

Oncology-related products: Aloxi® (palonosetron hydrochloride) injection, Halaven® (eribulin mesylate), Lenvima® (lenvatinib) capsules

Patient and Reimbursement Assistance Website eisaireimbursement.com

PATIENT ASSISTANCE $0 Co-Pay Program com/-/media/Files/XRay/Halaven/ Commercially insured patients Halaven-0Copay-Enrollment-Form. The Eisai Patient prescribed Halaven or Lenvima pdf) signed by both you and your Assistance Program may be eligible for the $0 Co-Pay patient. Eisai has created the Patient Assis- Program. Under this program, com- tance Program for customers who mercially insured patients pay a $0 Step 2: If the patient is determined need assistance paying for certain co-pay on each prescription with an to be eligible, they will be sent a Eisai medications. This program annual limit. Limits vary depending Welcome Letter for the Halaven $0 provides medications at no cost to on the Eisai medication you have Co-Pay Program stating they are financially needy patients who meet prescribed. eligible for benefits. program eligibility criteria. • For patients prescribed Halaven, the maximum benefit paid by Eisai Step 3: Fax the Explanation of For Halaven, Eisai has created Inc. will be $18,000 per year. Benefits (EOB) or detailed Specialty the Halaven Patient Assistance • For patients prescribed Lenvima, Pharmacy receipt for the Halaven Program for customers who need Eisai Inc. provides up to $40,000 claim to 844.745.2350. The assistance paying for Halaven. This per year to assist with out-of- following information should be program provides Halaven at no pocket costs. included: cost to financially needy patients • Patient’s information including who meet program eligibility Enrollment in the $0 Co-Pay full name criteria. Healthcare providers can Program is automatic if the patient • Date of service call the program at 1.866.61.EISAI is receiving Lenvima from Accredo • Cost of the medication (1.866.613.4724), Monday through or Biologics and is required when • Amount covered by the insurance Friday, 8:00 am to 8:00 pm ET to receiving Lenvima from another • Patient’s responsibility: deductible; determine eligibility. source. Complete and submit the co-payment; and co-insurance. Lenvima Intake Form (lenvima. To enroll for Lenvima, complete and com/pdfs/specialty-pharmacy-in- Step 4: If the patient’s claim is submit the Lenvima Eisai Assis- take-form.pdf) or call 1.866.61. approved, the appropriate funding tance Program Enrollment Form EISAI (1.866.613.4724) for more based on the patient’s out-of-pocket (http://www.eisaireimbursement. information. costs will be loaded onto the com/-/media/Files/XRay/Lenvima/ patient’s card and a confirmation LENVIMA-Eisai-Assistance- If you have prescribed Halaven there letter will be sent to you and your Program-Enrollment-Form.pdf) is a multi-step enrollment process, patient. or call 1.866.61.EISAI outlined below: (1.866.613.4724) for more Restrictions and Conditions information. Step 1: Complete and submit an Eligibility Criteria: Good toward enrollment form (eisaireimbursement. the purchase of prescribed, eligible

32 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 33 Eisai

Eisai medication. No substitu- tions permitted. Save this card REIMBURSEMENT to reuse with each prescription. ASSISTANCE Not available to patients enrolled in state or federal healthcare The Eisai Assistance programs, including Medicare, Program Medicaid, Medigap, VA, DoD, or The Eisai Assistance Program TRICARE. May not be combined provides information to patients with any other coupon, discount, and healthcare professionals prescription savings card, free trial, regarding the patient’s insurance or other offer. Federal law prohibits benefits for coverage of certain Eisai the selling, purchasing, trading, or medications. counterfeiting of this card. Such activities may result in imprisonment For Halaven, agents can provide infor- of 10 years, fines up to $25,000, mation relating to payer-specific or both. Void outside the U.S. and policies for coverage, information where prohibited by law. Eisai Inc. regarding billing and coding reserves the right to rescind, revoke, requirements, and answer questions or amend this offer at any time regarding financial assistance without notice. Patients and phar- options. Call 1.866.61.EISAI macies are responsible for disclosing (1.866.613.4724) Monday through to insurance carriers the redemption Friday, 8:00 am to 8:00 pm ET for and value of the card and complying all billing, coding, coverage, and with any other conditions imposed financial assistance questions. by insurance carriers or third-party payers. The value of this card is not For Lenvima, specialists will contingent on any prior or future complete a full benefit investigation purchases. to understand the patients’ insurance coverage. If needed, specialists can The card is solely intended to also discuss options for financial provide savings on any purchase of assistance to help patients access the approved Eisai medication. Use Lenvima. Contact 1.866.61.EISAI of the card for any one purchase (1.866.613.4724) Monday through does not obligate the patient to Friday, 9:00 am to 6:00 pm ET. make future purchases of the same Eisai medication or any other product. For patients prescribed Lenvima, this offer is available to MA residents through June 30, 2019, and to all other patients through March 31, 2020. For patients prescribed Halaven, this offer is available to MA residents through June 30, 2019, and to all other patients through November 20, 2019.

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 33 Eli Lilly and Company

Eli Lilly and Company

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

Patient and Reimbursement Assistance Websites LillyPatientOne.com LillyCares.com

PATIENT ASSISTANCE Alimta, Cyramza, Erbitux, 3. Your patient’s application will be Lartruvo, or Portrazza for an reviewed to determine eligibility Lilly PatientOne FDA-approved indication 4. The program may provide support Lilly PatientOne (lillypatientone. • Patients must be commercially for doses with a date of service com) strives to offer reliable and insured. that falls within 120 days before individualized treatment support for the date the application is received eligible patients prescribed a Lilly Ineligible: by the program. Oncology product. For those who • Patients enrolled in Medicaid, After submitting the Lilly PatientOne qualify, help can be provided in the Medicare, Medigap, CHAMPUS, Co-pay Program application, patients following ways: DOD, VA, TRICARE, or any and providers will be informed of • Evaluate financial assistance state, patient, or pharmaceutical program enrollment status by Lilly options, including co-pay assistance program PatientOne, indicating whether the programs and independent patient • Patients enrolled in any other patient meets eligibility requirements. assistance foundations financial support program, Approved patients will receive a • Provide reimbursement assistance discount, or incentive program welcome letter and the co-pay card (eligibility determination, benefits involving Alimta, Cyramza, in the mail from Lilly PatientOne. investigation, prior authorization Erbitux, Lartruvo, or Portrazza Providers will be informed of patients’ assistance, appeals information). • Patients, pharmacists, and enrollment status through a faxed prescribers must not seek reim- letter with specific instructions on Lilly PatientOne Co-Pay bursement from health insurance how claims can be filed. The phy- Program or any third party for any part of sician’s office staff should remind With the Lilly PatientOne Co-Pay the benefit received by the patient patients to bring their co-pay card Program, eligible patients pay a $25 through this program. with them to their next appointment. co-pay for certain prescribed Lilly oncology products up to a $25,000 Patient Enrollment Steps: Have any questions? Call a Lilly annual maximum benefit for com- 1. Review program eligibility with Field Reimbursement Manager at mercially insured patients. There are your patient based upon the full 1866.4PatOne (1.866.472.8663), no income requirements. criteria listed in the application Monday through Friday, 9:00 am 2. Apply online at lillypatientone. to 7:00 pm ET. Eligibility criteria: com or download an application • Patient must be aged 18 years or (lillypatientone.com/assets/pdf/ Lilly Cares Foundation older patient_assistance_program_ The Lilly Cares Foundation, Inc., • Patients must be residents of the application.pdf) to complete and a separate nonprofit organization, United States or Puerto Rico fax with all required signatures to provides free Lilly medications to • Patients must be treated with 1.877.366.0585 qualifying patients. Some of the

34 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 35 Eli Lilly and Company

eligibility requirements for Lilly and are operated independently. to 1.877.366.0585. As you fill out the Cares oncology products are listed Funding availability changes weekly, form be sure to check all services that below: so contact a Lilly PatientOne your patient might need. The treating • Patient is a permanent, legal representative at 1.866.4PatOne physician will receive a response from resident of the United States or (1.866.472.8663) for the most Lilly PatientOne once the patient’s Puerto Rico recent updates. application has been reviewed. • Patient meets household income guidelines for the program Verzenio Savings Card PatientOne may: • Patient is not enrolled in The Verzenio Savings Card is • Conduct a benefits investigation to Medicaid, full LIS, or Veterans available to eligible commercially help verify coverage Benefits. insured patients. Eligible patients • Provide prior authorization • Patient has been prescribed an can receive the first 3 months of requirements for the patient’s infused or oral Lilly oncology Verzenio free. After the first 3 insurer medication and has no insurance, months, patients pay no more than • Provide templates, forms, and has Medicare Part D, or has $10 per month thereafter for up checklists for filing an appeal for insurance that does not cover the to 12 months of Verzenio with a denied claims for eligible Lilly prescribed medication $25,000 annual cap. Oncology products. (These forms • Patient has been prescribed an can also be found at lillypatient infused Lilly oncology medication This offer is invalid for patients one.com/financial-assistance) and has submitted an application without commercial insurance • Upon request provide status to the Lilly Cares program within coverage or those whose prescription updates for appeals that have been 180 days of treatment. claims are eligible to be reimbursed, filed for eligible Lilly Oncology in whole or in part, by any govern- products. Go to lillycareseservice.com or mental program. Offer void where complete the Patient Assistance prohibited by law. Offer may be Lilly PatientOne program specialists Program Application Form subject to monthly and annual cap are available Monday through (lillycares.com/_Assets/pdf/Lilly of wholesale acquisition cost plus Friday, 9:00 am to 7:00 pm ET. Call Cares_oncology_application_Program_ usual and customary pharmacy 1.866.4PatOne (1.866.472.8663). -Eligibility_Update.pdf) and fax it to charges. Additional details and Learn more at lillypatientone.com. 1.888.242.6230 in order to enroll. restrictions apply. Verzenio Continuous For more information, visit Lilly- To apply for the Verzenio Savings Care™ Program Cares.com or call 1.800.545.6962, Card, visit verzenio.com/hcp/ The Verzenio Continuous Care Monday through Friday, 8:00 am to savings-support and follow the Program provides patient support 5:00 pm ET. instructions there. throughout their metastatic breast cancer journey, offering access and Independent Patient REIMBURSEMENT assistance and ongoing services. Assistance Program ASSISTANCE Foundations The Verzenio Continuous Care There may be a way to help your Lilly PatientOne Program may help eligible patients underinsured patients get the Even if your patient is fully insured, minimize co-pay or out-of-pocket treatment they need with less a claim may still be denied. Lilly costs by providing the following financial stress. If your patients PatientOne offers benefits inves- services (the program is not a can’t afford their co-pay or coin- tigation and appeals assistance to guarantee of coverage): surance, Lilly PatientOne provides qualified, insured patients. If a patient’s • A benefits investigation information about a number of claim is eligible, download and • Guidance through the specialty independent patient assistance complete a Lilly PatientOne Appli- pharmacy process programs that may be able to help cation Form at LillyPatientOne.com or • Identification of savings eligible patients. These foundations call 1.866.4PatOne (1.866.472.8663) opportunities. are not affiliated with Eli Lilly and to request a copy of the application be Company and have been established sent to you. Fax the completed form

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 35 Eli Lilly and Company

Ongoing services: • Reiterating Verzenio treatment information (like dosing and adverse events) that providers outlined in their office • Guiding patients back to the provider office if they are experiencing side effects or have questions regarding their treatment • Connecting patients to relevant disease state content and Verzenio information.

To enroll, download and complete the Verzenio Prescription and Continuous Care Enrollment Form (verzenio.com/assets/pdf/ HCP_Enrollment_Form.pdf) and fax all pages with prescriber and patient signature to 1.855.545.5957. Call 1.844.VERZENIO (1.844.837.9364) with additional questions or concerns.

MyRightDose Exchange Program With MyRightDose, your patient can continue their Verzenio therapy at the appropriate dose for them without the hassle of delays and at no cost. Medication is shipped to the patient as early as 48 hours after receipt of the enrollment form. Medication is available at no cost for up to three separate dose reduc- tions of between 5 and 28 days of therapy per exchange to any patient prescribed Verzenio for an FDA-approved indication Additional terms and conditions apply.

To enroll, download and complete the MyRightDose Dose Exchange Program Enrollment Form (verzenio. com/assets/pdf/MyRightDose_ Enrollment_Form.pdf) and fax the entire form to 1.833.665.6329. For more information, call 1.833.557.2417, Monday through Friday, 9:00 am to 6:00 pm ET, or visit verzenio.com.

36 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 37 EMD Serono and Pfizer

EMD Serono, Inc. and Pfizer, Inc.

Oncology-related product: Bavencio® (avelumab) injection

Patient and Reimbursement Assistance Website coverone.com

PATIENT ASSISTANCE CoverOne Co-Pay Enrollment in the co–pay assistance Assistance Program program does not guarantee assis- CoverOne™ Patient CoverOne provides co-pay assi- tance. Whether an expense is eligible Assistance Program stance for privately insured Bavencio® for the CoverOne co-pay assistance CoverOne includes a patient assis- (avelumab) injection 20 mg/mL benefit will be determined at the tance program that provides Bavencio patients with co-pay/co-insurance time the benefit is paid. Eligible at no charge for patients who meet responsibilities who meet the co-pay expenses must be in con- certain income, insurance (i.e., program eligibility criteria. nection with a separately paid claim uninsured), and residency eligibility for Bavencio administered in an out- criteria. To determine patient eligi- Privately insured patients may apply patient setting, which is otherwise bility, patients and providers should for assistance through the CoverOne covered by a private or commercial complete a CoverOne Enrollment Co-pay Assistance Program by insurance plan. Form (https://www.coverone.com/ faxing a completed CoverOne content/dam/web/health-care/ Enrollment Form to 1.800.214. The patient co-pay assistance biopharma/web/CoverOne/ 7295. Government-insured patients, program is not contingent on any Documents/USAVE10160118a(2)_ including Medicare and Medicaid past or commercial sale of Bavencio. CoverOne%2Enrollment%20Form_ beneficiaries, are not eligible for The co-pay program does not assist Digital%20Update.pdf) and fax the CoverOne Co-Pay Assistance with inpatient hospital claims or in the completed form and proof of Program. Limits, terms, and condi- any bundled payment arrangement income to 1.800.214.7295 prior to tions apply. Full terms and conditions where there is no separate patient treatment. for co-pay assistance can be found at co-pay for Bavencio, and does not coverone.com. assist with healthcare premiums or Patient assistance is not applied drug administration services. retroactively. A CoverOne rep- CoverOne will notify patients resentative will notify patients and providers of the eligibility REIMBURSEMENT and providers as soon as possible determination as soon as possible. ASSISTANCE with the patient’s eligibility Enrolled patients may be eligible determination. for a $0 co-pay for each treatment CoverOne for Bavencio, up to a maximum of Reimbursement Support NOTE: The CoverOne patient assi- $30,000 per year. Once the annual Services stance program is a philanthropic co-pay assistance limit is reached, CoverOne™ will help providers and program for patients in need, and is enrolled patients are responsible for patients understand the specific not contingent on any past or future paying all co-pays and any balance coverage and reimbursement guide- commercial sale for Bavencio. not covered by CoverOne. lines for Bavencio. Reimbursement support services include:

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 37 EMD Serono and Pfizer

• Insurance benefit verification • Prior authorization assistance Active Listening 101 • Information on relevant billing codes for Bavencio (HCPCS, CPT, ICD-10-CM, NDC) Active listening is a communication technique that requires the listener • Denied/underpaid claims to feed back what is heard to the speaker by re-stating or paraphrasing assistance what was heard in the listener’s own words. Active listening improves • Payer research (non-patient personal relationships, reduces misunderstanding and conflicts, strengthens specific) cooperation, and fosters understanding. The skill is proactive, accountable, • Medicare, private payers, State and professional. Medicaid • Alternate funding research. Active listening is comprised of three primary elements: comprehension, retention, and response. EMD Serono, Inc. and Pfizer, Inc. Comprehension—develop a shared meaning between parties through tone do not guarantee coverage and/or of voice, use of vocabulary and context, and speech pattern. reimbursement for Bavencio. Retention—take notes if necessary. Coverage, coding, and reimbursement policies vary significantly Response—respond both verbally and non-verbally. by payer, patient, and setting of care. Actual coverage and reim- Active Listening Tactics bursement decisions are made by • Listen and hear rather than waiting to speak. individual payers following the receipt of claims. Patients and • Watch body language. healthcare professionals should • Find common ground. always verify coverage, coding, and • Paraphrase the speaker’s words back to him or her as a question. reimbursement guidelines on a payer (“I see/hear/feel like you are afraid of…”) and patient-specific basis. • Suspend your own frame of reference and judgments. Please fax a completed CoverOne • Validate what the speaker is saying and feeling (“You seem to feel angry, Enrollment Form to 800.214.7295 is that because…?”) to request services. Barriers to Active Listening • Distractions • 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

38 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 39 Exelixis

Exelixis, Inc.

Oncology-related products: Cabometyx® (cabozantinib) tablets, Cometriq® (cabozantinib) capsules

Patient and Reimbursement Assistance Websites ease.us cometriq.com/hcp/access/

PATIENT ASSISTANCE rience a payer decision delay of 5 and eligibility rules apply. To apply, days or more. Limited to on-label download the EASE Dose Exchange Cabometyx Exelixis indications. Additional restrictions Form (cabometyxhcp.com/ Access Services® may apply. downloads/DoseExchangeForm. Exelixis Access Services (EASE) • At your request, EASE can pdf) and fax it to 1.844.901.EASE provides a variety of support to provide support with benefits (1.844.901.3273). help your patients get started on investigations (BIs), prior authori- treatment as soon as possible. EASE zation (PA) assistance, and appeals Cometriq Exelixis Access can meet the unique needs of your support and follow-up. Services patients and practice at each step Exelixis Access Services (EASE) is along the access journey. EASE Case To apply for these services, a personalized support program Managers are your single point of download and complete the EASE that provides information about contact at EASE and can provide Enrollment Form (cabometyxhcp. how patients can afford Cometriq the status of your patients’ access com/downloads/CABOMETYX- treatment. Specialists at EASE are journey, offer prompt support with EASEEnrollmentForm.pdf) and the available by phone to help with: payer coverage, financial assistance, EASE Patient Authorization Form • Ordering Cometriq and treatment coordination, and (cabometyxhcp.com/downloads/ • Financial assistance provide proactive follow-up. CABOMETYXPatientAuthoriza • Information about Cometriq. • The EASE Co-pay program lowers tionForm.pdf) and fax the forms to co-pays to no more than $10 per 1.844.901.EASE (1.844.901.3273). Exelixis Access Services is designed month for eligible commercially For more information, call to minimize financial barriers to insured patients. Additional 1.844.900.EASE (1.844.900.3273), therapy for commercially insured restrictions and eligibility rules Monday through Friday, 8:00 am to patients. Funding specialists are apply. Visit activatethecard. 8:00 pm ET. available to assist in enrolling com/7311 to enroll eligible eligible patients into available patients. EASE Dose Exchange Program patient assistance programs. • The EASE Patient Assistance The EASE Dose Exchange Program • The Co-pay Assistance Program Program helps eligible patients can help ensure the continuity of provides help with out-of-pocket who cannot afford their drug your patient’s care by providing a costs for patients who meet the costs receive Cabometyx free of lower dose when a dose adjustment program’s eligibility requirements. charge. Additional restrictions and is required. Patients receive a • The Patient Assistance Program eligibility rules apply. one-time supply of Cabometyx to provides Cometriq free of charge • The Cabometyx Quick Start help them transition to a lower dose; to patients who do not have Program helps your newly pre- 15 days of free product are provided insurance coverage and who meet scribed eligible patients quickly in the event a dose reduction is eligibility requirements. receive their therapy if they expe- required. Additional restrictions

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 39 Exelixis

• Alternative funding investigation provides assistance with identification of alternate funding for Insurance Verification Form people who do not qualify for our sponsored programs. Update q New q Patient Name:

For more information and to ID/SSN #: Patient Insurance ID enroll in EASE for Cometriq, call 1.855.253.EASE (1.855.253.3273). Group Policy # Insurance Company:

REIMBURSEMENT Primary Insurance? Secondary? Tertiary? ASSISTANCE Authorization/referral #

Cometriq Exelixis Access Name of Contact Date/Time of Auth: Services Exelixis Access Services has Phone/Fax/Address for Auth: dedicated oncology support specialists to assist healthcare profes- Effective Date: PCP: Tel # sionals, including: • Benefit coverage specialists to Specific Pharmacy Requirement: support benefit investigations, q Mail order: prior authorizations, appeals, and delivery coordination Co-insurance/Co-pay: • Appeals specialists to assist with further authorization Cap for drugs or diagnosis: $ requirements. Catastrophic Coverage or Stop-loss When? For more information, call 1.855.253.EASE (1.855.253.3273). 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

40 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 41 Genentech

Genentech, Inc.

Oncology-related products: Alecensa® (alectinib) capsules, Avastin® (bevacizumab), Cotellic® (cobimetinib) tablets, Erivedge® (vismodegib), Gazyva® (obinutuzumab), Herceptin® (trastuzumab), Herceptin HylectaTM (trastuzumab and hyaluronidase-oysk), Kadcyla® (ado-trastuzumab emtansine), Perjeta® (pertuzumab) for injection, Rituxan® (rituximab), Rituxan Hycela® (rituximab and hyaluronidase human), Tarceva® (erlotinib), Tecentriq® (atezolizumab), Venclexta® (venetoclax), Zelboraf® (vemurafenib) tablets

Patient and Reimbursement Assistance Website genentech-access.com

PATIENT ASSISTANCE contacted to discuss the application Approved patients pay as little as outcome and any next steps. $5 for their prescribed Genentech Genentech Access BioOncology products with an Solutions Genentech BioOncology® annual benefit limit of $25,000 per The Genentech Patient Co-pay Assistance Program product. The $5 co-pay applies to Foundation This co-pay card helps patients pay FDA-approved Genentech combina- The Genentech Patient Foundation for prescription medication costs. tion products. Retroactive requests gives free Genentech medicine to Qualified patients must: for assistance may be honored for people who don’t have insurance • Be covered by commercial or qualifying patients if the infusion coverage or who have financial private insurance or prescription fill occurred within concerns. Patients will get free • Receive a Genentech BioOncology 120 days prior to enrollment and the Genentech medicine if they: product for an FDA-approved patient meets all eligibility criteria • Do not have insurance or coverage indication at the time of infusion. No physical for their Genentech medicine and • Not participate in a govern- card is needed; patients simply need their household makes less than ment-funded healthcare program, their Member ID. $150,000 per year such as Medicare, Medicaid, • Have insurance, can’t afford their Medigap, VA, DoD, or TRICARE To get started, call 855.MYCOPAY out-of-pocket costs, have used • Be 18 years of age and older (855.692.6729) or visit Copay all available financial assistance, • Currently live and receive AssistanceNow.com. and meet certain income require- treatment in the United States or ments (found online at gene. U.S. Territories Referrals to Co-pay com/patients/patient-foundation/ • Not be receiving assistance Assistance Foundations see-if-you-qualify). through the Genentech Patient If patients need help with their Foundation or any other co-pay co-pay for Genentech medications, To get started, fax the completed charitable organization. Genentech Access Solutions can refer Enrollment Form (gene.com/ • There is no income requirement them to an independent co-pay assis- download/pdf/Genentech_Patient_ for the Genentech BioOncology tance foundation. An independent Foundation_Enrollment_Form.pdf) Co-pay Assistance Program. co-pay assistance foundation is a to 833.999.4363. Once an eligibility charitable organization that gives determination has been made, both financial assistance for medicines. the patient and prescriber will be

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 41 Genentech

Independent co-pay assistance If the request for a PA is not granted, • Service request management: foundations have their own rules for your BioOncology Field Reim- Search for open or closed service eligibility. Genentech cannot guarantee bursement Manager (BFRM) or requests initiated online or via a foundation will help the patient, but Access Solutions Specialist can work fax for easier service request can refer to a foundation that supports with the patient and provider to management, re-enrollment, or the disease state. This information is determine next steps. recertification. provided as a resource. Genentech • Service request alerts: When the does not endorse or show financial Appeals provider logs in to My Patient preference for any particular foun- If the patient’s health insurance Solutions, icons notify the dation. Listed foundations are not the plan has issued a denial, a BFRM provider which patient service only ones that might be able to help. or Access Solutions Specialist can requests require follow-up. provide resources as the patient To get started, visit genentech-access. and provider prepare an appeal To register, visit genentech-access. com, select a medication, and follow submission per the patient’s plan com and follow the instructions. the directions for specific indications. requirements. For assistance, call 866.422.2377, Monday through Friday, 9:00 am to REIMBURSEMENT If a plan issues a denial: 8:00 pm ET. ASSISTANCE • The denial should be reviewed, along with the health insurance Genentech Access plan’s guidelines to determine Solutions what to include in your patient’s Benefits Investigation appeal submission Genentech Access Solutions can • The BFRM or Access Solutions conduct a benefits investigation (BI) Specialist has local payer coverage to help you determine if a Genentech expertise and can help determine medicine is covered, which specialty specific requirements for the pharmacy (SP) the health insurance patient. plan prefers, and if patient assistance might be needed. The potential Sample letters and additional outcomes of a BI are: considerations are available • Treatment is covered at genentech-access.com by • Prior authorization is required selecting the prescribed medi- • Treatment is denied. cation and selecting the “Forms and Documents” section. Appeals A BI can be initiated once the cannot be completed or submitted Statement of Medical Necessity by Genentech Access Solutions on a (SMN) and Patient Authorization provider’s behalf. and Notice of Request (PAN) are submitted. Forms can be found My Patient Solutions™ by going to genentech-access.com, My Patient Solutions is an online selecting the prescribed medication, tool to help you enroll and manage and selecting the “Forms and your Genentech Access Solutions Documents” section. service requests. Features of My Patient Solutions: Prior Authorization Assistance • Paperless enrollment: Enroll Access Solutions can help you patients entirely online using elec- identify if a prior authorization tronic signatures. (PA) is necessary and offer resources • Full benefits investigation reports: as to obtain it. PA support can be Review benefits investigation provided once the SMN and PAN reports for all patients enrolled in are submitted. Genentech Access Solutions.

42 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 43 Heron Therapeutics

Heron Therapeutics

Oncology-related products: Cinvanti® (aprepitant) injectable emulsion, Sustol® (granisetron) extended-release injection

Patient and Reimbursement Assistance Website heronconnect.com

PATIENT ASSISTANCE for Cinvanti or Sustol with the Enrollment Form (heronconnect.com/ availability of copay assistance from pdfs/Practice-Copay-Assist-Program- Heron Connect™ Heron Therapeutics. When appli- Enroll-Form.pdf). Once the practice Heron Therapeutics is committed to cable, patients may also be eligible enrollment form is complete, indi- making a difference in patients’ lives for deductible assistance up to $200 vidual patients can be enrolled with innovative products and a suite per treatment. Limitations apply. by completing the Patient Copay of support services. Heron Connect Assistance Program Registration provides support programs that meet Offer not valid as follows: (a) Form (heronconnect.com/pdfs/ the needs of patients and providers. patients covered under Medicare, Patient-Copay-Assist-Program- Our access solutions include: Medicaid, or any federal or state Registration-Form.pdf). Fax forms to • Convenient access for eligible program; (b) where plan covers 1.844.504.8652. patients through $0 copay, treatment for the patient for the deductible assistance up to $200 entire cost of the prescription drug. Heron Connect Patient per treatment, and patient assis- Patients pay $0 per copay per dose Assistance Program tance programs per 12-month calendar period. Eligible patients may choose • Comprehensive support for When applicable, deductible assis- to enroll in the Heron Connect practices to assist with patient tance up to $200 per treatment will Patient Assistance Program (PAP). benefit coordination be covered. For cash-paying patients, This program is for patients with • Dedicated reimbursement the program will cover $150 per pre- financial hardship who meet counselors to help with patient scription up to $1,800 per calendar program eligibility criteria to receive enrollment, appeals, product year. Eligibility is for 12 months, Heron medications at no cost. access, and more after which patient will need to Heron Therapeutics reserves the • The Heron Commitment Program™, reapply for continued assistance. right, at its sole discretion, to discon- which helps mitigate the financial tinue the Heron Connect Patient burden of qualifying claim denials To verify benefits and enroll your Assistance Program or change the when programs are met. patients, download and complete the qualifications at any time. All patient Insurance Verification and Program information remains confidential. For more information on Heron Enrollment Form (heronconnect.com/ Product supply for the program Connect, call 1.844.HERON11 pdfs/Insurance-Verification-and- depends on availability. (1.844.437.6611), Monday through Program-Enrollment-Form.pdf) and Friday, 8:00 am to 8:00 pm ET. fax the form to 1.844.504.8652. To verify benefits and enroll your Practices that verify benefits directly patients, complete the Insurance Heron Connect Copay can use simplified registration at Verification and Program Enrollment Assistance Program heroncopay.com. Those practices Form (heronconnect.com/pdfs/ Commercially insured patients can can also complete a one-time Insurance-Verification-and- benefit from $0 out-of-pocket costs Practice Copay Assistance Program Program-Enrollment-Form.pdf).

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 43 Heron Therapeutics

Fax the form along with the pre- REIMBURSEMENT scription for the Heron medication ASSISTANCE to 1.844.504.8652. Heron Connect™ Heron Commitment Program™ Heron Connect services provide the Heron Therapeutics is dedicated access solutions you need: to ensuring patients and providers • Dedicated reimbursement coun- have access to Heron medications. selors. Your counselor will be a The Heron Commitment Program single point of contact for your helps mitigate the economic burden practice to help patients with of denials; in the event of a quali- enrollment in Heron Connect fying claim denial, the program will programs and insurance ver- credit your practice for the cost of ification; assist with prior the administered medication when authorization, appeals, billing, program requirements are met. reimbursement, and coding; More information on this program is track outcomes; and provide available at heronconnect.com/pdfs/ other services to support patients Heron-Commitment-Program-Infor- and help them secure product mation-Sheet.pdf. coverage. • Prior authorization and appeals The Heron Commitment Program support. Sample forms and letters and the other product support are available online at heron programs offered by Heron Thera- connect.com. peutics do not impose any purchase • Drug replacement. In the event obligation at any time or in any that the Heron medication is manner. Use of Cinvanti and/or determined to be unfit for patient Sustol may be discontinued at any use or has expired, Heron Ther- time, without penalty. A qualifying apeutics will replace the affected claim denial can be reviewed for units. Call Heron Connect for the Heron Commitment Program more information at 1.844. when, for a patient covered under HERON11 (1.844.437.6611). commercial insurance, the following Determination will be made by the criteria have been met, and doc- manufacturer of the drug. umentation confirms: (a) the • Product information. Call if you verification of benefits, conducted by have a clinical inquiry or would the provider and/or Heron Connect, like to report an adverse event meets all of the payer criteria and/ related to the Heron medication. or policy requirements, (b) the submitted claim for the Heron For more information on Heron product is denied, and (c) the claim Connect, call 1.844.HERON11 has been denied again by the com- (1.844.437.6611), Monday through mercial payer after the first level of Friday, 8:00 am to 8:00 pm ET. appeals process has been followed.

To enroll your practice, complete a one-time Heron Com- mitment Program Enrollment Form (heronconnect.com/pdfs/ Heron-Commitment-Program- Practice-Enrollment-Form.pdf) and fax the form to 1.844.504.8652.

44 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 45 Incyte Corporation

Incyte Corporation

Oncology-related products: Jakafi® (ruxolitinib) tablets

Patient and Reimbursement Assistance Website incytecares.com

PATIENT ASSISTANCE Completed hard-copy forms should or less than 600% of the Federal be faxed to 1.855.525.7207. Once Poverty Level (FPL), whichever is IncyteCARES the IncyteCARES program receives greater. In addition, patients insured IncyteCARES (Connecting to the completed enrollment form, the through Medicare, Medicaid, Access, Reimbursement, Education program will: TRICARE, and healthcare exchange and Support) is designed to help • Confirm the patient’s drug plans are not eligible. An Incyte eligible patients gain access to coverage for Jakafi CARES nurse can help determine Jakafi. IncyteCARES provides a • Coordinate their Jakafi pre- if patients qualify for patient assis- single point ofcontact through an scription with the appropriate tance. For additional help, call an oncology-certified nurse. Incyte- specialty pharmacy IncyteCARES registered nurse at CARES nurses work one-on-one • Determine if the patient qualifies 1.855.4.JAKAFI (1.855.452.5234). with patients to identify ongoing for any financial assistance support, resources, and referrals • Provide ongoing education Co-pay/Coinsurance Assistance to help meet their needs during and support. If patients are eligible, the treatment with Jakafi. Specifically, co-pay/coinsurance assistance IncyteCARES nurses can help For additional help, call an program for Jakafi may be able to eligible patients with: IncyteCARES registered nurse at reduce their co-payment to as little • Reimbursement support 1.855.4.JAKAFI (1.855.452.5234). as $25 per month. Patients may • Delivery coordination be eligible for co-pay/coinsurance • Financial assistance options Uninsured Patients assistance if they have commercial • Temporary access for coverage Patients who do not have pre- or private insurance, they are a delays scription drug coverage for Jakafi resident of the U.S. or Puerto Rico, • Connection to support resources may be eligible to receive the they are 18 years of age or older, • Ongoing education and support drug free of charge through the and they have a valid prescription IncyteCARES Patient Assistance for Jakafi for an FDA-approved To enroll, patients and providers will Program. This program helps people treatment. Uninsured, cash-paying need to complete either the online who do not have a prescription drug patients are not eligible. Not valid enrollment form (incytecares.com/ plan, as well as those whose plans for patients covered under state enrollment.aspx#) or hard-copy have turned them down for Jakafi or federally-funded healthcare enrollment form (incytecares. treatment. Certain conditions apply programs, such as Medicare, com/pdf/jakafi-enrollment-form. for prescription savings. Patients Medicaid, or TRICARE. Patients pdf). Please note that once online may be eligible if they are a resident must have minimum out-of-pocket enrollment has begun, the user will of the U.S. or Puerto Rico and their cost of $25.01 to redeem this card not be able to exit and return to it household size and annual income and must contribute $25 towards later as their information will not be meet certain criteria, including that out-of-pocket cost. Patients must saved. earning less than $125,000 a year disclose the use of the co-pay card to

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 45 Incyte Corporation

their insurers. Amount of savings of Each of these organizations has its the purchase of Jakafi will not exceed own set of rules, and Incyte does not $11,977 per month and $25,000 per influence or control them in any way. year. Limit one 30-day supply per 30 days. Card is valid for one year after REIMBURSEMENT activation, after which time a card ASSISTANCE must be reactivated to continue use. This offer expired for Massachusetts IncyteCARES residents on July 1, 2017. A trained IncyteCARES nurse will work with providers and patients to If you have any questions, please call provide assistance with prescription 1.855.4.JAKAFI (1.855.452.5234). drug plan requirements that must be met before patients can get access to Temporary Access Jakafi. Some healthcare plans may Eligible patients experiencing require prior authorization, which coverage delays can receive a free means they will ask for more infor- supply of Jakafi. To be eligible, mation from the provider before patients must submit a proof of deciding to pay for the patient’s insurance claim verifying the delay. Jakafi. IncyteCARES will work with Free product is offered to eligible physicians to provide the necessary patients without any purchase information to their patient’s contingency or other obligation. healthcare plan. For more information, contact an IncyteCARES registered nurse at In addition, if a healthcare plan will 1.855.4.JAKAFI (1.855.452.5234). not pay for Jakafi, IncyteCARES can help providers and patients under- Referral to an Independent stand what needs to be provided to Nonprofit Organization the healthcare plan to appeal the For patients who are not eligible for denial. While IncyteCARES cannot assistance through IncyteCARES apply for the appeal, it can help or who need additional support providers and patients determine beyond what the program can the steps they may need to take to provide, IncyteCARES can identify overturn the denial. and refer patients to other resources, such as independent nonprofit orga- For more information, call nizations (INOs) or foundations. 1.855.4.JAKAFI (1.855.452.5234).

INOs may be able to assist patients with arranging transportation to and from medical appointments, travel cost assistance, copay/coinsurance assistance, and emotional and educational support.

INOs may also be able to provide the following services to patients and caregivers: • Support counseling for emotional, social, and practical concerns • Information about support groups and referrals to local services at no cost.

46 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 47 Ipsen

I psen Biopharmaceuticals, Inc.

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

Patient and Reimbursement Assistance Website ipsencares.com

PATIENT ASSISTANCE ister injections at no additional insurance, IPSEN CARES may be cost to the patient (for Somat- able to offer the contact information IPSEN CARES® uline® Depot) for independent nonprofit foun- The IPSEN CARES® (Coverage, • Benefits verification and reim- dations that may be able to offer Access, Reimbursement & bursement support. financial assistance. The maximum Education Support) program was copay benefit per prescription for designed to simplify the process of Somatuline Depot cash-paying patients is $1,666.66, applying and getting coverage for Copay Program subject to the $20,000 annual Ipsen medications, as well as related The Somatuline Depot Copay maximum. For more information, care, for adult patients, pediatric Program is available to eligible visit ipsencares.com/onivyde- patients, and their parents. Eligible commercially insured and uninsured patient-support or call 866.435.5677. patients may save on out-of-pocket patients by enrolling in IPSEN prescription costs for certain Ipsen CARES. Most eligible patients pay Patient Assistance Program products. Patients and providers no more than $5 per prescription The Patient Assistance Program can call 866.435.5677, Monday to a maximum annual benefit (PAP) is designed to provide Ipsen through Friday, 8:00 am to 8:00 pm of $20,000. Program exhausts medications at no cost to eligible ET, to begin the enrollment process. after 12 months, 13 injections, patients. Patients may be eligible to You can also enroll patients online or a maximum annual benefit of receive free medication if they are at: ipsencaresportal.biologicsinc. $20,000, whichever comes first. The experiencing financial hardship, have com/Account/Login or download maximum copay benefit per pre- no insurance coverage, and received the drug specific enrollment form scription for cash-paying patients is a prescription for on-label use of an from ipsencares.com and fax the $1,666.66, subject to the $20,000 Ipsen medication. Eligibility does not signed and completed form to annual maximum. Patients must guarantee approval for participation 1.888.525.2416. IPSEN CARES enroll annually to receive continued in the program. offers the following services for benefit. For more information, visit patients: ipsencares.com/somatuline-patient- Both the patient and the healthcare • Help minimize delays or interrup- support or call 866.435.5677. provider have to complete the appli- tions in treatment cation. To enroll, visit ipsencares. • Provide financial assistance, Onivyde Copay Program com/, select the appropriate medi- including copay assistance or free The Onivyde Copay Program is cation, and either apply online or medication to eligible patients available to eligible commercially complete the drug-specific form and • Coordination of specialty insured and uninsured patients by fax it to 1.888.525.2416. For further pharmacy delivery enrolling in IPSEN CARES. Patients assistance, call 1.866.435.5677, • Arrange for eligible patients to pay $0 per order up to a maximum Monday through Friday, 8:00 am to have a home health administration annual copay benefit of $20,000. For 8:00 pm ET. nurse visit their home to admin- patients with government-provided

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 47 Ipsen

REIMBURSEMENT by payers, and make recommen- ASSISTANCE dations for next steps based on payer policy IPSEN CARES • Appeals Support: IPSEN CARES IPSEN CARES offers the following will provide information on the Reimbursement Assistance services payer-specific process required to to patients and providers: submit a level I or a level II appeal • Benefits erification:V IPSEN as well as provide guidance as CARES will help determine needed throughout the appeals patient’s coverage, restrictions (if process. applicable), and copayment or co-insurance amount Visit ipsencares.com for more • Prior Authorization: IPSEN information. Questions? Call CARES will provide information 866.435.5677, Monday through on documentation required Friday, 8:00 am to 8:00 pm ET.

2018–2019 Federal Poverty Guidelines* Family Size 100% 133% 138% 250% 400%

1 $12,140 $16,146 $16,753 $30,350 $48,560

2 $16,460 $21,892 $22,715 $41,150 $65,840

3 $20,780 $27,637 $28,676 $51,950 $83,120

4 $25,100 $33,383 $34,638 $62,750 $100,400

5 $29,420 $39,129 $40,600 $73,550 $117,680

6 $33,740 $44,874 $46,561 $84,350 $134,960

7 $38,060 $50,620 $52,523 $95,150 $152,240

8 $42,380 $56,365 $58,484 $105,950 $169,520

* Federal poverty level amounts are higher in Alaska and Hawaii.

48 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 49 Janssen

Janssen Biotech, Inc.

Oncology-related products: Balversa™ (erdafitinib), Darzalex® (daratumumab), Doxil® (doxorubicin HCl liposome injection), Erleada™ (apalutamide), Procrit® (epoetin alfa), Sylvant® (siltuximab), Yon- delis® (trabectedin), Zytiga® (abiraterone acetate)

Patient and Reimbursement Assistance Website JanssenCarePath.com

PATIENT ASSISTANCE may be available for patients taking *The nurse program is limited to Janssen medications. Janssen CarePath education for patients about their Janssen CarePath • Support for patients using com- Janssen therapy, its administration, Janssen CarePath is your one source mercial or private insurance and/or their disease, and is not for resources focused on access, • Support for patients using gov- intended to provide medical advice, affordability, and treatment support ernment insurance replace a treatment plan from the for your patients. The Care Coordi- • Support for patients without patient’s doctor or nurse, or provide nator team supports all prescribed insurance coverage case management services. Janssen medications. Janssen • Patient Account and Provider CarePath can help make it easier Portal for convenient online Call a Janssen CarePath Care Coor- for you and your patients to get the enrollment of eligible patients into dinator at 877.CarePath (877.227. resources you both may need. Savings Programs. 3728), Monday through Friday, 8:00 am to 8:00 pm ET. Multilingual Access Support Treatment Support phone support is available. Janssen CarePath helps verify Janssen CarePath provides addi- insurance coverage for patients tional support to patients, including: Janssen CarePath Savings and provides reimbursement infor- Program mation. Offerings include: Education tools Janssen CarePath Savings Program • Benefits investigation support • Patient education brochures can help eligible patients with their • Prior authorization support and • Web-based resources out-of-pocket costs for their Janssen status monitoring • Assistance with identifying medication. Depending on their • Information on the exceptions and independent organizations which health insurance plan, savings may appeals process may provide assistance with costs apply toward co-pay, co-insurance, • Coding and billing information, if associated with travel to and from or deductible. Patients may be needed treatment (not available for all eligible if they are using commercial • Triage to specialty pharmacy Janssen products) or private health insurance to cover providers, if needed • Access to nurses who can a portion of their medication costs • Patient Account and Provider answer patients’ questions about for the Janssen medication. There Portal for convenient online benefits treatment with Erleada is no income requirement. This investigation, prior authorization • AdvocacyConnector.com program is not available to indi- support, and other resources. viduals who use any state or federal Adherence tools government-subsidized healthcare Affordability Support • Personalized reminders program to cover a portion of Janssen CarePath can help find afford- • Access to the Care4Today® medication costs, such as Medicare, ability assistance for patients with that Connect Mobile App. Medicaid, TRICARE, Department

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 49 Janssen

of Defense, or Veterans Adminis- eligibility requirements, visit Jans- We have no control over these inde- tration. Patients confirm that they senCarePath.com/Darzalex. pendent foundations and can only will not seek reimbursement from refer the patient to a foundation any of these programs or from Janssen CarePath Savings that supports their disease state. pharmaceutical patient assistance Program for Yondelis We do not endorse any particular foundations and accounts such as Eligible patients will pay $5 per foundation. a Flexible Spending Account (FSA), infusion, with a $20,000 maximum Health Savings Account (HSA), or program benefit per calendar year. JanssenPrescriptionAssistance.com Health Reimbursement Account Program provides a rebate to provides information on afford- (HRA). patients for out-of-pocket medi- ability programs and information cation costs for Yondelis. Program about independent foundations† Janssen CarePath Savings does not cover cost to give patients that may have funding available Program for Erleada their infusion. To learn more about to help patients with medication Eligible patients pay $0 per month, the Janssen CarePath Savings costs for Janssen medications. with a $15,000 maximum program Program for Yondelis, including Or call Janssen CarePath at 877- benefit per calendar year or one-year full eligibility requirements, visit CarePath (877-227-3728) to speak supply, whichever comes first. JanssenCarePath.com/Yondelis. with a Care Coordinator about Patients get instant savings on their affordability programs that may be out-of-pocket costs for Erleada. Janssen CarePath Savings available. To learn more about the Janssen Program for Sylvant CarePath Savings Program for Eligible patients will pay $5 per Johnson & Johnson Erleada, including full eligibility infusion, with a $20,000 maximum Patient Assistance requirements, visit JanssenCarePath. program benefit per calendar year. Foundation com/Erleada. Program provides a rebate to patients The Johnson & Johnson Patient for out-of-pocket medication costs for Assistance Foundation, Inc. (JJPAF) Janssen CarePath Savings Sylvant. Program does not cover cost is an independent, nonprofit organi- Program for Zytiga to give patients their infusion. To learn zation that is committed to helping Eligible patients pay $10 per more about the Janssen CarePath eligible patients without insurance month, with a $12,000 maximum Savings Program for Sylvant, coverage receive prescription program benefit per calendar year or including full eligibility requirements, products donated by Johnson & one-year supply, whichever comes visit JanssenCarePath.com/Sylvant. Johnson operating companies. first. Patients get instant savings To see if they might qualify for on their out-of-pocket costs for Other Affordability assistance, please have your patient Zytiga. To learn more about the Options contact a JJPAF program specialist Janssen CarePath Savings Program For patients using government at 800.652.6227, Monday through for Zytiga, including full eligibility insurance or patients without Friday, 9:00 am to 6:00 pm ET, or requirements, visit JanssenCarePath. insurance coverage, Janssen visit the foundation website at www. com/Zytiga. CarePath can provide information JJPAF.org. about independent resources Janssen CarePath Savings that may be able to help with REIMBURSEMENT Program for Darzalex out-of-pocket medication costs: ASSISTANCE Eligible patients will pay $5 per • State-Sponsored Programs infusion, with a $20,000 maximum • Medicare Savings Program Janssen CarePath program benefit per calendar year. • Medicare Part D Extra Help – Provider Portal Program provides a rebate to Low-Income Subsidy Janssen CarePath understands that patients for out-of-pocket medi- • Independent Foundations.† navigating payer processes and cation costs for Darzalex. Program finding cost support options may does not cover cost to give patients †Independent co-pay assistance seem complicated at times. That’s their infusion. To learn more about foundations have their own rules why we’ve created an enhanced the Janssen CarePath Savings for eligibility. We cannot guarantee Provider Portal experience. The Program for Darzalex, including full a foundation will help your patient. Janssen CarePath Provider Portal

50 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 51 Janssen

gives healthcare providers and pharmacies 24-hour online access to: Tips for Filing Claims • Request benefits investigations • Review the status of benefits For Electronic Claims DO… investigations • Enroll your eligible, commercially 3 Verify, file, and keep all transmission reports. insured patients in the Janssen 3 Track clearinghouse claims to ensure successful transmission. CarePath Savings Program • View savings program transac- 3 Ensure your computer software is consistent with the clean tions for enrolled patients claims rules. • Receive notifications when new information is available or action 3 Verify that your software correctly prints the CMS-1500 claim form. is required on the Portal. 3 Call your software vendor, if needed, to address the above Create a Provider Portal account at two items. JanssenCarePathPortal.com. For Paper Claims DO…

Janssen CarePath Patient 3 Use only original claim forms (printed in red drop-out ink). Account Patients can create a Janssen 3 Avoid folding claims, if possible. CarePath Account at MyJanssen CarePath.com where they can: 3 Resist using terms such as “refiled claim,” “second request,” • Check their insurance coverage for or “corrected claim.” Janssen medications 3 Avoid handwritten claims. • Check eligibility and enroll in the Janssen CarePath Savings Program 3 Use all UPPERCASE letters. • Manage Savings Program transactions 3 Stay inside the lines of each block. • Sign up for treatment reminders. 3 Ensure claims are printed darkly. Content paid for and written by For Paper Claims DON’T… Johnson & Johnson Health Care Systems Inc. 3 Use any punctuation or decimals.

3 Send unnecessary attachments.

3 Use staples or paperclips.

3 Attach “post-it” notes.

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

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 51 Kite Pharma

Kite Pharma

Oncology-related products: Yescarta® (axicabtagene ciloleucel) suspension for IV infusion

Patient and Reimbursement Assistance Website kitekonnect.com

PATIENT AND REIMBURSEMENT ASSISTANCE How to Check for Patient Understanding Kite Konnect™ A diagnosis of cancer is never easy. In addition to complex information Kite Konnect is committed to about cancer treatment, patients and families must now understand and helping patients and healthcare deal with the cost of treatment. It is even harder when patients have trouble teams throughout Yescarta paying for their medications and treatment. For some patients, the finan- treatment. Kite Konnect can assist cial difficulties begin when they are first diagnosed with cancer. For others, with: financial pressures build up over the course of treatment. Before you can • Patient enrollment: Hospital help these patients and families, you must first ensure that they understand portal access, cell order com- the information you are sharing. Here are some statements or questions pletion, and leukapheresis you can use to check how well a patient or family member understands the scheduling information you are providing. • Reimbursement support: Benefits 3 Please stop me if you do not understand something. I will be happy to investigation, claims appeals, and go over the information again. support for eligible uninsured and underinsured patients 3 Let me know if I am going too fast or too slow. • Logistics support: Connecting 3 Does this information make sense? patients with independent founda- 3 Have I answered your question(s)? tions to help with transportation and housing 3 Do you have other questions at this time? • Ongoing order tracking and 3 Are you still with me? communication. 3 Am I overwhelming you with this information? Yescarta is only available at author- 3 Should I go into more detail? ized treatment centers. To get your 3 Tell me if I am unclear or if I use words that you do not understand. patients started with Yescarta, enroll your patient using the Kite Konnect 3 Please stop me if I begin to explain something that you already Hospital Portal (kitekonnect. understand. force.com/s/). For further infor- 3 Is the information I am providing helpful to you? mation, contact 1.844.454.KITE (1.844.454.5483). Source. ACCC Financial Advocacy Network. accc-cancer.org/FAN

52 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 53 Merck

Merck

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

Vaccine: Gardasil®9 (Human Papillomavirus 9-valent Vaccine, Recombinant)

Patient and Reimbursement Assistance Websites merckaccessprogram.com merckhelps.com

PATIENT ASSISTANCE Merck Patient To enroll, patients and providers must Assistance Program complete the Patient Assistant Program Merck Access Program The Merck Patient Assistance Enrollment Form (merckhelps.com/ The Merck Access Program (MAP) Program provides product free docs/MPAP_Enrollment_Form_ can help answer questions about of charge to eligible individuals, CORP-1083762-English.pdf in access and support, including: primarily the uninsured who, without English, merckhelps.com/docs/ • Benefit investigations, prior autho- assistance, could not afford needed MPAP_Enrollment_Form_Spanish. rizations, and appeals Merck medicines. A single appli- pdf in Spanish) and mail it to the • Insurance coverage for patients cation may provide up to 1 year of address on the form. If you have any • Co-pay assistance for eligible product free of charge to eligible questions about the Merck Patient patients individuals, and an individual may Assistance Program including the • Referral to the Merck Patient reapply as many times as needed. status of an application, please call Assistance Program for eligibility 1.800.727.5400, Monday through determination Eligibility criteria include: Friday, 8:00 am to 8:00 pm ET. • Reimbursement. • Patient is legal resident of the United States or U.S. territories The Merck Co-pay Assistance To enroll, visit merckaccessprogram. • Patient does not have insurance Program for Keytruda com/hcp/, select the prescribed med- or other coverage for your pre- The Merck Co-pay Assistance ication, and use the online portal or scription medicine Program offers assistance to eligible complete the appropriate sections of • Patient meets income requirements. patients who need help affording the enrollment form. For hardcopy Keytruda. Co-pay assistance may forms, print and fax the completed Sometimes exceptions need to be be available for patients who: form to 855.755.0518. A program made based on the patient’s individual • Are a resident of the United States representative will contact the circumstances. If the patient does not (including Puerto Rico) patient and provider. meet the prescription drug coverage • Have private health insurance that criteria, their income meets the covers Keytruda under For further assistance, call program criteria, and there are special a medical benefit program 855.257.3932, Monday through circumstances of financial and medical • Have been prescribed Keytruda Friday, 8:00 am to 8:00 pm ET. hardship that apply to their situation, for an FDA-approved indication they can request an exception be made.

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 53 Merck

• Meet financial eligibility Sometimes exceptions need to be Appeals requirements as set forth in made based on the patient’s indi- MAP may be able to help the the terms and conditions (found at vidual circumstances. If the patient provider understand the information merckaccessprogram-key does not meet the prescription drug needed for an appeal submission if truda.com/hcp/the-merck- coverage criteria, their income meets the provider has submitted a claim copay-assistance-program/) the program criteria, and there are and the claim has been denied. The • Meet all other criteria of the special circumstances of financial appeal checklist and sample appeal program. and medical hardship that apply to letter can help you to understand their situation, they can request an the documents and information that Once enrolled, eligible privately exception be made. may be helpful when filing insured patients pay the first an appeal. Please check for $25 of their co-pay per infusion. To enroll, patients and providers payer-specific requirements. The maximum co-pay assistance must complete the Vaccine Patient program benefit is $25,000 per Assistant Program Enrollment Form If you have any questions about patient per calendar year (based on (merckhelps.com/docs/VPAP_ MAP reimbursement support income). Enrollment_Form_English.pdf) services, Merck Access Program rep- and fax it from a participating resentatives are available Monday To enroll, visit merckaccessprogram- licensed prescriber’s office to through Friday, 8:00 am to 8:00 pm keytruda.com/hcp/the-merck- 1.800.528.2551. The application ET, at 1.855.257.3932. copay-assistance-program/ and must be submitted and approved use the online portal or download prior to administration of the the appropriate enrollment forms. vaccine in order to qualify. Complete and submit the forms to 855.755.0518. If the patient is inel- If you have any questions about igible for this program, they may be the Merck Vaccine Patient Assi- able to get help from an independent stance Program, please call co-pay assistance foundation. A rep- 1.800.293.3881, Monday through resentative can provide information Friday, 8:00 am to 8:00 pm ET. about independent foundations with their own eligibility criteria and REIMBURSEMENT application process. ASSISTANCE

Merck Vaccine Patient Merck Access Program Assistance Program for Benefit Investigations Gardasil®9 MAP can contact insurers to request The Merck Vaccine Patient Assis- coverage and benefits information. tance Program provides vaccines Visit the specific product site for free of charge to eligible individuals, additional resources. primarily the uninsured who, without assistance, could not afford Prior Authorizations needed Merck vaccinations. Eligi- If a prior authorization is required, bility criteria include: or for assistance in understanding • Patient is legal resident of the if a prior authorization is required, United States or U.S. territories MAP may be able to help. The prior and is 19 to 26 years of age authorization checklist and sample • Patient does not have insurance letter can help you to understand or other coverage for your pre- the documents and information that scription medicine may be helpful when seeking a prior • Patient meets income requirements. authorization. Please check for payer-specific requirements.

54 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 55 Mylan

Mylan

Oncology-related products: Fulphila® (pegfilgrastim-jmdb) injection

Patient and Reimbursement Assistance Website mylanadvocate.com

PATIENT ASSISTANCE To contact experienced and caring (Part D or otherwise), Medicaid, MYLAN ADVOCATE patient access Medigap, VA or DOD, or TriCare MYLAN ADVOCATE™ specialists, call 1.833.695.2623, (regardless of whether a specific MYLAN ADVOCATE provides Monday through Friday, 9:00 am prescription is covered by such access support for Fulphila and to 8:00 pm ET. Patient support government program); if the patient Fulphila’s associated services. services and resources are available is Medicare eligible and enrolled in Services include insurance benefits 24 hours a day, 7 days a week, via an employer-sponsored health plan verification, coding information, the MYLAN ADVOCATE portal at or prescription benefit program for and field reimbursement support. mylanadvocate.com. retirees; or if the patient’s insurance MYLAN ADVOCATE can also plan is paying the entire cost of this identify solutions such as copay MYLAN ADVOCATE Co-Pay prescription. This program is valid in assistance for commercially insured Assistance Program Massachusetts through June 30, 2019, patients, patient assistance for The MYLAN ADVOCATE Co-Pay unless applicable law is amended or qualified patients who cannot afford Assistance Program is open to both extended by Massachusetts. their medication, and contact infor- new and existing eligible patients mation for other resources, such as who are residents of the U.S. or REIMBURSEMENT third-party charitable foundations, Puerto Rico and who have com- ASSISTANCE as appropriate. mercial insurance. This co-pay • Commercially insured patients may assistance program can be used to MYLAN ADVOCATE™ be able to access Fulphila for $0 reduce the amount of an eligible A team of dedicated patient access copay. There are no income rescri- patient’s out-of-pocket expense for specialists is available to answer calls tions. Eligibility criteria apply. Fulphila up to the full amount of and address concerns or questions • Patients without insurance the patient’s out-of-pocket expense regarding: coverage for Fulphila who cannot per prescription up to $10,000 per • Coding and billing information. afford their medication may be 12-month period. Mylan can provide information able to receive their medication about applicable coding for free of charge. Eligibility require- This co-pay assistance program is Fulphila and its administration. ments apply based on residency, not valid for uninsured patients (Note: Coding information income, and other factors. or patients whose commercial is provided for informational Contact MYLAN ADVOCATE insurance coverage does not purposes only; the physician must for more information. include Fulphila; patients who determine the appropriate code • MYLAN ADVOCATE can help are covered in whole or in part for each patient and payer.) identify other resources, such by any state or federally funded as state programs or third-party healthcare program, including, but charitable foundations, that may not limited to, any state pharmaceu- be able to assist your patients. tical assistance program, Medicare

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 55 Mylan

• Insurance coverage verification. Mylan can help check patient Patient Assistance Checklist for Uninsured Patients insurance plan enrollment status. • Benefit investigation. Mylan can 3 I have received the chemotherapy order written by the physician? assist in researching patient-spe- 3 I have met with the patient to assess his or her ability to pay for cific insurance coverage, coding, treatment? and billing requirements for 3 Based on this meeting, is the patient able to pay out-of-pocket for drug(s)? Fulphila and its administration; q YES q NO verify patient cost-sharing require- If no, list drug(s) below and continue on with checklist. ments including deductible, copay, coinsurance, out-of-pocket 3 Is a replacement drug program available? q YES q NO maximum, and amounts met If yes, identify drug and program: to date; determine payer access requirements (e.g. specialty 3 Does the patient qualify for this program? q YES q NO pharmacy, in-office dispensing, If no, state reason(s) why: etc.); and prepare a Summary of Benefits that documents all 3 If yes, I have completed all the necessary forms and paperwork for the findings. drug replacement program. q YES q NO • Prior authorization/reauthori- If no, state reasons why: zation assistance and tracking. Mylan can assist in checking 3 Does the patient need drug(s) that are not available through a drug PA requirements, submission replacement program? q YES q NO details, and track status, as well as If yes, identify which drugs: provide offices with payer-specific forms. 3 Is Foundation funding assistance available for any of these drug(s)? • Coverage/claim appeal assistance q YES q NO and tracking. Mylan can verify If yes, identify Foundation(s) and drug(s): appeal requirements and track the status and resolution of appeals. 3 I have completed all the necessary forms and paperwork for these • Field reimbursement support. A Foundation funding program(s). q YES q NO reimbursement expert from your If no, state reasons why: area can visit your cancer program for live educational programs 3 Does the patient qualify for charity care within from my clinic, cancer on coverage and reimbursement center, hospital, or healthcare system? q YES q NO information or to assist with If yes, identify program: questions related to Fulphila access. 3 I have completed all the forms and paperwork necessary to apply for this charity care. q YES q NO For more information call MYLAN If no, state reasons why: ADVOCATE at 1.833.695.2623, Monday through Friday, 9:00 am 3 Is there a balance or money owed related to treatment? q YES q NO to 8:00 pm ET, or go to mylan If yes, identify balance: advocate.com. 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

56 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 57 Novartis

Novartis Pharmaceuticals Corporation

Oncology-related products: Afinitor® (everolimus) tablets, Afinitor Disperz® (everolimus) tablets for oral suspension, Arzerra® (ofatumumab) injection, Exjade® (deferasirox) tablets for oral suspension, Farydak® (panobinostat) capsules, Femara® (letrozole) tablets, Gleevec® (imatinib mesylate) tablets, Jadenu® (deferasirox) tablets, Kisqali® (ribociclib) tablets, Kymriah® (tisagenlecleucel) suspension for IV infusion, Mekinist® (trametinib) tablets, Odomzo® (sonidegib), Promacta® (eltrombopag) tablets, Rydapt® (midostaurin) capsules, Sandostatin® (octreotide acetate) for injection, Sandostatin® LAR Depot (octreotide acetate for injectable suspension), Tafinlar® (dabrafenib) capsules, Tasigna® (nilotinib) tablets, Tykerb® (lapatinib) tablets, Votrient® (pazopanib) tablets, Zykadia® (ceritinib) capsules

Patient and Reimbursement Assistance Websites hcp.novartis.com/access https://www.patient.novartisoncology.com

PATIENT ASSISTANCE • Enroll online by visiting • Sandostatin LAR Depot pharma.us.novartis.com/info/ • Tafinlar The Novartis Patient patient-assistance/patient- • Tasigna Assistance Foundation assistance-enrollment.jsp, selecting • Tykerb This foundation provides assistance the appropriate Novartis medi- • Votrient to patients experiencing financial cation from the drop down menu, • Zykadia. hardship who have no third-party and following the instructions insurance coverage for their medicines. • Call 1.800.277.2254 to enroll by Eligible patients may pay no more To be eligible for the Novartis Patient phone. than $25, subject to a maximum Assistance Fund, patients must: benefit of $15,000 per calendar • Be a U.S. resident Novartis Oncology year. Find out if this program is • Meet income criteria, which vary Universal Co-Pay Card right for your patient by calling by medication, and provide proof Novartis Oncology created its 1.877.577.7756 or by going to: of income Universal Co-Pay Program (copay. copay.novartisoncology.com and • Not have private or public novartisoncology.com) to help with clicking on the name of the medi- prescription coverage. (NOTE: prescription costs for all the medic cation. This offer is not valid under Exception process exists.) tions listed below: Medicare, Medicaid, or any other • Afinitor federal or state program. Novartis Questions? Contact the Novartis • Exjade reserves the right to rescind, revoke, Patient Assistance Foundation at: • Farydak or amend this program without 1.800.277.2254, or go online to: • Femara notice. Limitations apply. Read https://www.patient.novartisoncology. • Gleevec program terms and conditions at: com. There are two ways • Jadenu copay.novartisoncology.com. to enroll in the program: • Kisqali • Mekinist • Promacta • Rydapt

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 57 Novartis

Independent • Insurance benefits verification, Charitable Foundations including information on denial of There are a variety of independent coverage and/or appeals charitable foundations that may be • Patient Support Counselors who able to provide additional assis- are able to provide information in tance. Select your condition at over 160 languages http://www.patient.novartiso • Patient Navigators who provide cology.com/financial-assistance/ 1-on-1 support specific to a private-insurance/ to see a list of patient’s medication (varies by some of the foundations that may medication) be able to help. • Free trial of medication or free access programs (varies by All organizations listed are indepen- medication; this offering is for dent from Novartis Pharmaceu- approved uses/indications only) ticals Corporation. Novartis has no • Dedicated case managers with a financial interest in any organization private extension for you to reach listed, but may provide occasional them directly when needed funding support to these organiza- • A combination of PANO case tions. All descriptions are copyright of managers and/or field reim- the respective organizations. Novartis bursement managers are available is not responsible for the actions of to help depending on the com- any of these organizations. plexity of a patient’s case.

Kymriah Cares™ To enroll your patient, visit From information on financial assis- hcp.novartis.com/access. To learn tance to patient support programs, more, call 1.800.282.7630. Kymriah Cares has resources to help eligible patients throughout their treatment journey. Whether they have questions about Kymriah or insurance coverage, Kymriah Cares is here to help.

To learn more, please call 1.844. 4KYMRIAH (1-844.459.6742), 8:00 am to 8:00 pm ET.

REIMBURSEMENT ASSISTANCE Patient Assistance Now Oncology (PANO) Novartis Oncology is committed to helping patients get the medicines they need. Getting access to medications can sometimes be difficult or confusing. Patient Assistance Now Oncology (PANO) offers tools and support designed specifically to help make that process easier, including:

58 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 59 Pfizer

Pfizer, Inc.

Oncology-related products: Aromasin® (exemestane tablets), Bavencio® (avelumab) injection (co-marketed with EMD Serono, Inc.), Besponsa® (inotuzumab ozogamicin), Bosulif® (bosutinib) tablets, Camptosar® (irinotecan HCl injection), DaurismoTM (glasdegib), Ellence® (epirubicin hydrochloride injection), Emcyt® (estramustine phosphate sodium capsules), Ibrance® (palbociclib), Idamycin PFS® (idarubicin hydrochloride for injection), Inlyta® (axitinib) tablets, Lorbrena® (lorlatinib), MylotargTM (gemtuzumab ozogamicin), Sutent® (sunitinib malate), Talzenna® (talazoparib), Torisel® (temsirolimus) injection, TrazimeraTM (trastuzumab-qyyp), Vitrakvi® (larotrectinib) (co-marketed with Loxo Oncology Inc.), Vizimpro® (dacomitinib), Xalkori® (crizotinib) capsules, Zinecard® (dexrazoxane for injection)

Patient and Reimbursement Assistance Website pfizeroncologytogether.com

PATIENT ASSISTANCE • Commercially insured patients Together Co-Pay Savings Program. with commercial, private, Through the Pfizer Oncology Pfizer Oncology employer, and state health Together Co-Pay Savings Card, Together™ insurance marketplace coverage patients pay a $0 co-pay per eligible Pfizer Oncology Together offers • Medicare/government insured monthly prescription for select Pfizer personalized assistance to help your patients with Medicare/Medicare medications. The maximum annual patients get the treatment you’ve Part D, Medicaid, and other gov- benefit is $25,000. prescribed. Their support com- ernment insurance plans plements the care patients receive • Uninsured patients without any The card is not valid for prescrip- in your office and goes beyond form of healthcare coverage. tions that are eligible to be reim- financial assistance and treatment bursed, in whole or in part, by information. From connecting To enroll, download the Support Medicaid, Medicare, TRICARE, patients to third-party organi- Services & Patient Assistance or other federal or state healthcare zations that help patients get to Enrollment Form (pfizeroncology programs, as well as the Govern- treatment-related appointments to together.com/sites/default/files/ ment Health Insurance Plan available finding local patient support events Pfizer%20Oncology%20Together in Puerto Rico. For more infor- and programs—Pfizer here to help. %20Enrollment%20Form.pdf) mation, call 1.877.744.5675 or visit and fax the completed form to pfizeroncologytogether.com and Pfizer offers access and reim- 1.877.736.6506. For live support, select the medication. bursement services to help your call 1.877.744.5675, Monday patients get Pfizer medication, through Friday, 8:00 am to 8:00 pm Pfizer Patient Assistance including benefits verification, ET. Visit pfizeroncologytogether.com Program prior authorization assistance, and for more information. Eligible patients may receive up to appeals assistance. Pfizer will work a 90-day supply of medication for with your patients to help find the Pfizer Oncology Together free while applying for Medicaid. If right financial support, regardless of Co-Pay Savings Program patients do not qualify for Medicaid, insurance coverage. There’s assis- Commercially insured patients may they may be able to get a 1-year tance for: qualify for the Pfizer Oncology supply of medication for free through

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 59 Pfizer

the Pfizer Patient Assistance Program, REIMBURSEMENT To get started, fax a completed or at a savings through the Pfizer ASSISTANCE enrollment form to 1.877.736.6506 savings Program. Patients must meet or call 1.877.744.5675, Monday eligibility requirements and reapply Pfizer Oncology Together through Friday, 8:00 am to 8:00 pm as needed. Pfizer Oncology Together wants ET. to help you and your staff find To qualify for free medicine, patients solutions for access and reim- must: bursement issues that may arise. • Have been prescribed an eligible Pfizer will assist with handling Pfizer medicine benefits verification, offering prior • Live in the United States or a US authorization and appeals assistance, territory and coordinating with specialty • Have no prescription coverage or pharmacies. not enough coverage to pay for • Benefits verification: Pfizer can their Pfizer medicine conduct a benefits verification • Meet certain income limits to determine the patient’s health (income limits vary by product insurance coverage, including and household size). co-pay responsibility and out- of-pocket cost for eligible Pfizer The Pfizer Patient Assistance medication. Program is a joint program of Pfizer • Prior authorization: Pfizer will Inc. and the Pfizer Patient Assis- coordinate with the insurer to tance Foundation. The Pfizer Patient determine all prior authorization Assistance Foundation is a separate requirements, where and how legal entity from Pfizer Inc. with to submit requests, and typical distinct legal restrictions. For more turnaround times. Pfizer will information, call 1.877.744.5675 or also follow up with the payer on visit pfizeroncologytogether.com and behalf of the patient and track the select the medication. process until a final outcome is determined. Support from Independent • Appeals assistance: If your Charitable Organizations patient’s claim is denied, Pfizer For Medicare or government-insured can work with you to review patients, Pfizer can assist in searching the reason for the denial and for financial support that may help you better understand the be available from independent appeals process. Once the appeal charitable foundations. These foun- is submitted, Pfizer will follow up dations exist independently of Pfizer with the payer on behalf of the and have their own eligibility criteria patient and track the process until and application process. Availability a final outcome is determined. of support from the foundations • Pharmacy coordination: Pfizer is determined solely by the foun- provides support in identifying dations. If independent charitable specialty pharmacy options, or foundation support is not available, you and your staff can continue Pfizer may be able to help insured to work directly with specialty patients receive Pfizer medications pharmacies. for free through the Pfizer Patient Assistance Program.

60 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 61 Pharmacyclics

Pharmacyclics, LLC

Oncology-related products: Imbruvica® (ibrutinib)

Patient and Reimbursement Assistance Website imbruvica.com/youandi

PATIENT ASSISTANCE website at jjpaf.org to see if they • Coordinating Imbruvica delivery might qualify for assistance. YOU&i™ Instant Savings To learn more about the Program YOU&i™ Start Program YOU&i Support Program, call Through this program, patients with The YOU&i Start Program can 1.877.877.3536, Monday through commercial insurance and who meet provide access to Imbruvica for Friday, 8:00 am to 8:00 pm ET. eligibility requirements will pay no new patients who are experi- more than $10 per prescription for encing insurance coverage decision Nurse Call & Support Imbruvica. This program is not delays. Eligible patients who have Resources valid for patients enrolled in been prescribed Imbruvica for an The You&i Support Program has Medicare, Medicaid, or other state FDA-approved indication and nurses who are available to support or federal programs. Maximum limit who are experiencing an insurance patients with: of $24,600 per calendar year. coverage decision delay greater than • A resource-filled Starter Kit To enroll in the program, visit 5 business days can receive a free designed for new patients con- https://sservices.trialcard.comCoupon/ 30-day supply of Imbruvica. The taining disease information, tips YouAndI/. For more information, call free product is offered to eligible on building a medication routine, 1.877.877.3536, Monday through patients without any purchase con- adherence tools, and more Friday, 8:00 am to 8:00 pm ET. tingency or other obligation. • Nurse call support personalized to patients’ preferences for frequency For patients with federally funded REIMBURSEMENT and method of contact Medicare, Medicaid, or commercial ASSISTANCE • Referrals of patients seeking insurance, YOU&i can also provide medical advice back to their information on independent founda- YOU&i™ Support Program healthcare providers. tions that may be able to provide The YOU&i Support Program is patients with additional financial a personalized program that helps Call 1.877.877.3536 for more infor- support. patients learn about access to mation about the You&i Support Imbruvica, find affordability support Program. The Johnson & Johnson Patient options, and sign up for information Assistance Foundation, Inc., may be and resources to support them along able to provide access to Imbruvica their treatment journey. Patients will to uninsured patients who lack the learn about access through: financial resources to pay for them. • Rapid benefits investigation Contact a JJPAF program specialist • Information on the prior at 1.800.652.6227, 9:00 am to 6:00 authorization process pm ET, or visit the foundation • Navigating the exception and appeals process

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 61 Puma Biotechnology

Puma Biotechnology

Oncology-related product: Nerlynx® (neratinib)

Patient and Reimbursement Assistance Website nerlynx.com/access-and-support

PATIENT ASSISTANCE Nerlynx Quick Start: The Nerlynx REIMBURSEMENT Quick Start program provides a ASSISTANCE Puma Patient Lynx™ 21-day supply of Nerlynx at no Puma Patient Lynx is designed to charge for eligible patients experi- Puma Patient Lynx™ provide patients with the support encing a delay in coverage through For patients prescribed with needed throughout their course of health insurance. If a gap in Nerlynx tablets, Puma Patient treatment. For patients prescribed with coverage extends beyond the first Lynx can conduct a benefits Nerlynx, Puma Patient Lynx provides 21 days and the patient or provider investigation, verify insurance the following support services: is actively pursuing coverage approval or coverage, and obtain through prior authorization/appeal, and submit necessary documen- Patient Assistance Program: For the patient may be eligible for one tation for patients requiring prior patients who are uninsured and 21-day refill. This program may authorization. meet certain financial qualifica- not be combined with another tions, Nerlynx can be provided for offer and is not eligible to patients For more information on the Puma free through the Patient Assistance without insurance or whose insurer Patient Lynx Support Program, call Program. Please call reimbursement has made a final coverage determi- 1.855.816.5421, Monday through specialists at 1.855.816.5421 for nation. Patients must reside in the Friday, 9:00 am to 8:00 pm ET. more information. United States or its territories.

Co-Pay Savings Program: Com- Referrals can also be made to mercially insured, eligible patients nonprofit foundations for patients treated with Nerlynx may pay who are not commercially insured as little as $10 per prescription and are in need of financial support. (limitations apply). Patients will be enrolled through their specialty To enroll, download and complete the pharmacy. To verify your patients’ Puma Patient Lynx Enrollment Form eligibility and enroll them in the (nerlynx.com/pdf/enrollment-form. co-pay card program, visit https:// pdf) and fax it to 844.276.5153. For sservices.trialcard.com/Coupon/ more information on the Puma nerlynx or call Puma Patient Lynx Patient Lynx Support Program, call at 1.855.816.5421. 1.855.816.5421, Monday through Friday, 9:00 am to 8:00 pm ET.

62 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 63 Regeneron and Sanofi

Regeneron Pharmaceuticals, Inc., and Sanofi Genzyme

Oncology-related products: Libtayo® (cemiplimab-rwlc)

Patient and Reimbursement Assistance Website libtayohcp.com/accessinglibtayo

PATIENT ASSISTANCE copays, coinsurance, or insurance Enrollment%20Form_US-LIB deductibles are not covered. Addi- -1001.pdf) and check the box LIBTAYO Surround™ tional program conditions apply. in Section 1 marked “Copay LIBTAYO Surround™ helps eligible See https://www.libtayohcp.com/ for Assistance.” Complete the patients access Libtayo and navigate more information. enrollment form and fax it to the health insurance process. Visit 1.833.853.8362. libtayohcp.com for more infor- Patients are responsible for any • Providers or patients can call mation about this program, or call out-of-pocket cost for Libtayo that LIBTAYO Surround at 1.877. 1.877.LIBTAYO (1.877.542.8296), exceeds the program assistance limit LIBTAYO (1.877.542.8296), Option 1, Monday through Friday, of $25,000 per year, in addition Option 1, Monday through 8:00 am to 8:00 pm ET. to non–product-specific expenses Friday, 8:00 am to 8:00 pm ET. related to supplies, procedures, or A LIBTAYO Surround Reim- LIBTAYO Surround Copay physician-related services. To be bursement Specialist will guide the Program for Eligible eligible: caller through eligibility require- Commercially Insured Patients • Patients must have commercial or ments and the enrollment process. Eligible patients pay $0 out of private insurance, which includes Be sure to have patient contact pocket for Libtayo, which includes state or federal employee plans information and commercial any product-specific copay, and health insurance exchanges. insurance information, including coinsurance, and insurance deduct- (Note: patients who do not have payer and plan names, policy ibles—up to $25,000 in assistance commercial or private insurance and group numbers, and phone per year. There is no income are not eligible.) numbers. requirement to qualify for this • Patients must be residents of the program. United States or its territories or LIBTAYO Surround possessions. Patient Assistance This program is not valid for pre- • Other restrictions apply. Program scriptions covered by or submitted The LIBTAYO Surround Patient for reimbursement under Medicare, There are two ways to enroll Assistance Program helps eligible Medicaid, VA, DoD, TRICARE, or patients in the LIBTAYO Surround patients who are uninsured or who similar federal or state programs. Copay Program: lack coverage for Libtayo receive This program is not a debit card • Download the LIBTAYO Libtayo at no cost. Patient eligibility: program and does not cover or Surround Enrollment Form • Patients must be uninsured, lack provide support for supplies, pro- (libtayohcp.com/-/media/ coverage for Libtayo, or have cedures, or any physician-related EMS/Conditions/Oncology/ Medicare Part B with no supple- service associated with Libtayo. Brands/LibtayoHCP/pdf/ mental insurance coverage. General non–product-specific LIBTAYO%20Surround%20 • Patients must be residents of the

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 63 Regeneron and Sanofi

United States or its territories or be eligible and explain the benefits • The patient’s eligibility for possessions. they provide copay assistance • Patients must enroll in LIBTAYO • Answer questions about the appli- • Any additional coverage Surround by signing Section cation process for each program information to facilitate the 9 of the LIBTAYO Surround • Provide patients with the patient’s access to medication. Enrollment Form (libtayohcp. appropriate program’s contact • Prior authorization, appeal, and com/-/media/EMS/Conditions/ information. claims assistance. Oncology/Brands/LibtayoHCP/ pdf/LIBTAYO%20Surround%20 Potential alternate sources available Once the patient’s coverage require- Enrollment%20Form_US-LIB- for patients may include Medicaid, ments have been verified, LIBTAYO 1001.pdf) and the Health state health insurance exchanges, Surround is available to provide Insurance Portability and Medigap, state pharmaceutical assis- ongoing support to facilitate Accountability Act of 1996 autho- tance programs, and independent approval of and reimbursement for rization in Section 10. charitable foundations. Libtayo for eligible patients: • Patients must have an annual • Prior authorization support gross household income that Once an alternate source is iden- to review and explain payer does not exceed the greater of tified and the patient applies for requirements $100,000 or 500% of the federal assistance, a LIBTAYO Surround • Appeal assistance when prior poverty level. Reimbursement Specialist may be authorizations are denied • Other restrictions apply. able to follow up with the patient • Claims assistance to address and/or healthcare provider’s office questions as healthcare providers LIBTAYO Surround facilitates the staff about the status of the appli- prepare claims and to review the enrollment process. To assist patients cation and communicate the result. status of claims with the patient’s who wish to enroll in this program, a health insurer. LIBTAYO Surround Reimbursement REIMBURSEMENT Specialist is available to investigate ASSISTANCE the patient’s eligibility criteria, notify the healthcare provider about LIBTAYO Surround™ the patient’s eligibility, coordinate LIBTAYO Surround™ provides shipment of Libtayo to the healthcare assistance with the reimbursement provider’s practice or other site of process. To enroll, download the care, send confirmation of patient LIBTAYO Surround Enrollment enrollment in the LIBTAYO Surround Form (libtayohcp.com/-/media/ Patient Assistance Program, and EMS/Conditions/Oncology/Brands/ contact the healthcare provider’s LibtayoHCP/pdf/LIBTAYO%20 office to coordinate future shipments. Surround%20Enrollment%20Form_ US-LIB-1001.pdf), make sure each Identification of Alternate field is complete and accurate, sign Sources of Funding the form, and fax the completed LIBTAYO Surround may be able to form to 1.833.853.8362. help find alternate funding sources for patients without insurance Upon enrollment, a Reimbursement coverage or patients with inadequate Specialist can provide the following insurance coverage for Libtayo who assistance: need assistance with out-of-pocket • Benefits investigation, which medication costs. addresses: • How the medication may be To assist patients, a Reimbursement covered under the patient’s Specialist will: health plan • Identify alternate coverage • Acquisition options for the programs for which patients may patient’s medication

64 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 65 Sandoz

Sandoz, Inc.

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

Patient and Reimbursement Assistance Website zarxio.com/resources/patient-support

PATIENT ASSISTANCE dose or cycle of Zarxio and $0 out of online at qv.trialcard.com/zarxio. pocket for subsequent doses or cycles 2. Submit an online Sandoz One Sandoz One Source™ up to a maximum annual benefit of Source enrollment form at Sandoz One Source is a compre- $10,000. There is no income eligi- qv.trialcard.com/zarxiohub. hensive program designed to help bility requirement for this program. 3. Download and fax a completed simplify and support patient access Sandoz One Source enrollment for those prescribed Zarxio. Sandoz Maximum benefit of $10,000 annually. form to 1.844.726.3695. One Source is available to assist Prescription must be for an approved patients with: indication. This program is not health Questions? Call 1.844.SANDOZ1 • Benefit investigations insurance. This programis for insured (1.844.726.3691), Monday through • Prior authorization support patients only; cash-paying or uninsured Friday, 9:00 am to 8:00 pm ET. • Appeals support patients are not eligible. Patients are • Sandoz One Source Commercial not eligible if prescription for Zarxio is REIMBURSEMENT Co-Pay Program eligibility paid, in whole or in part, by any ASSISTANCE • Independent foundation information state or federally funded programs, • Patient assistance program including but not limited to Medicare Sandoz One Source™ • Billing and coding support (including Part D, even in the Sandoz One Source offers a variety • General payer policy information. coverage gap) or Medicaid, Medigap, of reimbursement assistance services VA, DOD, or TriCare, or private for patients and providers, including: To enroll, visit qv.trialcard.com/ indemnity plans that do not cover • Comprehensive insurance zarxiohub or download and complete prescription drugs, or HMO insurance verifications the enrollment form (zarxio.com/ plans that reimburse the patient for • Prior authorization support globalassets/zarxio7/resources/ the entire cost of their prescription when required by the insurance sandoz-one-source-enrollment-form. drugs, or where prohibited by law. company pdf) and fax it to 1.844.726.3691. • Billing and coding information Questions? Call 844.SANDOZ1 Co-Pay Program may apply to • Claims tracking information (844.726.3691), Monday through out-of-pocket expenses that occurred • Denials/appeals information Friday, 8:00 am to 8:00 pm ET. within 120 days prior to the date • General payer policy research. of the enrollment. Co-Pay Program Sandoz One Source may not be combined with any other You can download the enrollment Co-Pay Program rebate, coupon, or offer. Co-Pay form, or enroll your patients online The Sandoz One Source Commercial Program has no cash value. Sandoz via the Sandoz One Source Provider Co-Pay Program for Zarxio supports reserves the right to rescind, revoke, or Portal at zarxio.com/resources/ eligible, commercially insured patients amend this offer without further notice. patient-support. Call 1.844. with their out-of-pocket co-pay costs SANDOZ1 (1.844.726.3691), for Zarxio. Eligible patients may There are three ways to enroll: Monday through Friday, 9:00 am to pay $0 out of pocket for their first 1. Instruct your patients to enroll 8:00 pm ET with more questions.

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 65 Seattle Genetics

Seattle Genetics

Oncology-related products: Adcetris® (brentuximab vedotin)

Patient and Reimbursement Assistance Website seagensecure.com

PATIENT ASSISTANCE Coinsurance and Adcetris-related benefits within Deductible Assistance two business days of receiving the SeaGen Secure™ Patient For insured patients who cannot completed request, and the provider Assistance Program afford their coinsurance or copay, will receive a call to discuss the For patients with no insurance, the coinsurance and deductible assis- results and next steps. Patient Assistance Program provides tance is available. To be eligible, • Refer to sample claims form Adcetris at no cost. Assistance patients must have commercial (seagensecure.com/assets/docs/ begins on a temporary 3-month health insurance with coverage for Sample_CMS_1500_ADCETRIS. period and an alternative coverage Adcetris, be receiving Adcetris for an pdf) for billing guidance search is facilitated through SeaGen on-label indication, be a permanent • If patients need help with cost Secure. The drug must be ordered U.S. resident, and meet income sharing, they will be assessed for for each cycle. The patient must be requirements. If eligible, SeaGen eligibility for assistance or referred a permanent U.S. resident and meet Secure will send assistance to the to an independent foundation for income requirements. provider on behalf of the patient. co-pay assistance. The patient may receive assistance There are three ways to enroll: for the duration of their therapy if Claims and Appeals • Enroll online at seagensecure.com they remain eligible. There are some Assistance • Complete the Patient Assistance/ program limits/caps. SeaGen Secure Case Managers can Benefits Investigation Form help providers track claims to ensure (seagensecure.com/assets/docs/ REIMBURSEMENT they are being processed and paid USP-BVP-2015-0124(3)_SeaGen_ ASSISTANCE on time. For insured patients with Secure_PAP_Form_v03_inter- denied or underpaid claims, SeaGen active.pdf) and fax it to SeaGen Secure reimbursement Secure will assist with the appeal 855.557.2480 services include: and assess for patient assistance. • Call a SeaGen Secure case • Benefits investigation manager at 855.4SECURE • Prior authorization assistance To speak to a Case Manager, call (855.473.2873). • Billing and coding assistance 855.4SECURE (855.473.2873), • Claims and appeals assistance. option 1 for HCPs, Monday through For more information, call Friday, 9:00 am to 8:00 pm ET. 855.4SECURE (855.473.2873), Benefits Investigation Monday through Friday, 9:00 am to Once the enrollment form is 8:00 pm ET, and select option 1. received, a benefits investigation is conducted to determine an individual patient’s coverage for Adcetris. SeaGen Secure will fax providers a summary of the patient’s

66 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 67 Taiho Oncology

Taiho Oncology

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

Patient and Reimbursement Assistance Websites taihopatientsupport.com

PATIENT ASSISTANCE per treatment cycle. This reduction Oncology Patient Support offers the is available to all patients with following services to help improve Taiho Oncology Patient commercial prescription insurance access to Lonsurf, and to make the Support™ coverage for Lonsurf. treatment process as simple and Taiho Oncology Patient Support smooth as possible: offers the following services: There are three ways to enroll in • Access and reimbursement • Co-pay support for eligible, Taiho Patient Support: support, including benefit privately or commercially insured • Complete the Patient Enrollment investigations, assistance with patients. Such patients can receive Form in English (taihopatient prior authorizations to meet payer a Taiho Oncology Patient Support support.com/Content/downloads/ requirements, and claims appeals co-pay card for help with enrollment-form-english- assistance if coverage out-of-pocket expenses for March2018.pdf) or Spanish is denied. Lonsurf.* (taihopatientsupport.com/ • Specialty pharmacy • Patient Assistance Program. Taiho Content/downloads/enrollment- prescription coordination, Patient Support will research form-spanish-March2018.pdf) including prescription financial assistance options and fax it to 1.844.287.2559. triage, coordination with the for patients with no insurance • The patient completes the Patient in-network specialty pharmacy, coverage, insufficient prescription Enrollment Form online and self-dispensing practice, or coverage, or insufficient resources brings it to the provider’s office, hospital retail pharmacy, and com- to pay for treatment with Lonsurf. or the provider completes it munication with patients about Eligible patients may receive electronically. prescription status. Lonsurf at no cost based on • Call 1.844.TAIHO.4U • Personalized nurse support assistance, financial, and medical (1.844.824.4648), Monday is available for treatment plan criteria. through Friday, 8:00 am to 8:00 adherence upon request. • Alternate funding support. Taiho pm ET for help with enrollment. Patient Support will also refer eligible, publicly insured patients REIMBURSEMENT to nonprofit foundations that ASSISTANCE may be able to offer them co-pay assistance. They may also be Taiho Oncology Patient eligible for the Patient Assistance Support program. Taiho Oncology Patient Support will quickly investigate each patient’s *As of May 1, 2018, The co-pay coverage for Lonsurf and help them for all dose strengths of Lonsurf get access to the Lonsurf treatment has been reduced from $30 to $0 they have been prescribed. Taiho

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 67 Takeda Oncology

Takeda Oncology

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

Patient and Reimbursement Assistance Websites takedaoncology1point.com velcade.com/paying-for-treatment

PATIENT ASSISTANCE 8:00 am to 8:00 pm ET, for more old. Additional terms and condi- information. tions apply. Takeda Oncology 1Point™ Takeda Oncology 1Point: Takeda Oncology Co-Pay To enroll, visit takedaoncologycopay. • Works with healthcare providers Assistance Program com or call to speak with your Takeda and insurance companies to For patients with commercial Oncology 1Point case manager at help patients get started on their insurance concerned about their out- 1.844.T1POINT (1.844.817.6468), medication of-pocket costs for Alunbrig, Iclusig, option 2, Monday through Friday, • Identifies available financial and Ninlaro, the Takeda Oncology 8:00 am to 8:00 pm ET. assistance that may be right for Co-Pay Assistance Program may be patients able to help reduce the out-of-pocket Takeda Oncology Patient • Connects patients to additional costs associated with their medi- Assistance Program support services and resources. cation. Patients could pay as little as For patients who do not have $10 per prescription with an annual insurance or who do not have To enroll, download the Takeda maximum benefit of $25,000. insurance that covers their med- Oncology 1Point Enrollment ication, they may be eligible to Form (takedaoncology1point.com/ This offer cannot be used if you receive their medication through the pdf/Takeda_Oncology_1Point_ are a beneficiary of, or any part Patient Assistance Program at no Enrollment_Form.pdf) and fax of your prescription is covered or cost. To be eligible for the Patient the completed and signed form reimbursed by: (1) any federal or Assistance Program, patients must along with a copy of the patient’s state healthcare program (Medicare, meet certain clinical, financial, and insurance card and prescription to Medicaid, TRICARE, Veterans insurance coverage criteria. 1.844.269.3038. Administration, Department of Defense, etc.), including a state A Patient Assistance Program Appli- After the patient’s enrollment form or territory pharmaceutical assis- cation (https://www.takedaoncology is received and processed, a Takeda tance program, (2) the Medicare 1point.com/pdf/Takeda_Oncology_ Oncology 1Point case manager will Prescription Drug Program (Part Patient_Assistance_Program_ conduct a benefits verification to D), or if you are currently in the Enrollment_Form.pdf) must be determine the patient’s prescription coverage gap, Medicare Advantage submitted in order to confirm patient coverage and potential out-of-pocket Plans, Medicaid Managed Care or eligibility. Patient and provider must costs. A summary of coverage will Alternative Benefit Plans under the complete the form and fax it along be provided to the provider’s office Affordable Care Act, or Medigap, with a valid prescription for medi- within 2 business days. Call 1.844. or (3) insurance that is paying the cation to 1.844.269.3038. T1POINT (1.844.817.6468), entire cost of the prescription. option 2, Monday through Friday, Patients must be at least 18 years

68 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 69 Takeda Oncology

If the patient qualifies, they may 8:00 am to 8:00 pm ET. Fax of their medication at no cost. be enrolled for up to 1 year. Upon completed forms to: 800.891.9843. To receive a RapidStart supply, a enrollment, a Takeda Oncology Learn more online at velcade.com completed Takeda Oncology 1Point 1Point case manager will notify the or by calling 1.866.VELCADE Enrollment Form must be on file, patient and their healthcare provider. (1.866.835.2233) and choosing and a RapidStart Request Form A 1-month supply of their medication option 2. must be completed and submitted will be delivered to the patient at no (drug-specific forms are available at cost. Each month a Takeda Oncology REIMBURSEMENT takedaoncology1point.com.) Addi- 1Point case manager will confirm ASSISTANCE tional terms and conditions apply. with patient and provider that they are still being treated and are eligible Takeda Oncology 1Point™ Velcade Reimbursement to receive another month’s supply of Case managers at Takeda Oncology Assistance Program medication. 1Point are a patient’s connect to The Velcade Reimbursement personalized support. Once a patient Assistance Program (VRAP) helps Velcade Patient is enrolled in Takeda Oncology patients and providers navigate the Assistance Program 1Point, the program: reimbursement process. Call 1.866. If patients do not have any insurance • Works with the healthcare VELCADE (1.866.835.2233), option coverage, they may be eligible to provider and insurance company 2, Monday through Friday, 8:00 am participate in the Velcade Patient to help determine if medication is to 8:00 pm ET, to speak with a live Assistance Program. If patients covered. Reimbursement Case Manager about qualify for the program, Velcade will • Works with the patient’s insurance or coverage questions. The be delivered free of charge to their pharmacy to arrange the delivery hotline accepts calls from patients, treating physician. Patient eligibility of medication caregivers, physicians, and other is based on three factors: • Evaluates patient eligibility for healthcare professionals. 1. Household income available support and financial 2. Treatment setting assistance programs (terms and VRAP provides the following 3. Velcade prescribed for a use that is conditions apply) services to patients and providers: medically appropriate. • Connects patients to a range of • Insurance verification support services and additional • Claim appeals support (VRAP Patients who do not have insurance resources, such as transportation does not file claims or appeal coverage for Velcade must apply for assistance. claims for callers and cannot assistance through their healthcare guarantee success in obtaining professionals. To demonstrate To enroll, download the Takeda reimbursement) eligibility, they must complete an Oncology 1Point Enrollment • Identification of alternate and enrollment form and provide income Form (takedaoncology1point.com/ supplemental insurance coverage documentation, as well as health pdf/Takeda_Oncology_1Point_ options insurance information. It is strongly Enrollment_Form.pdf) and fax • Co-payment foundation support recommended that you enroll patients the completed and signed form information into the Patient Assistance Program along with a copy of the patient’s • Screening and enrollment of prior to the start of their treatment insurance card and prescription eligible patients into the Patient with Velcade. All enrollment forms to 1.844.269.3038. Call 1.844. Assistance Program must be received within six months T1POINT (1.844.817.6468), • Transportation. of the first treatment. option 2, Monday through Friday, 8:00 am to 8:00 pm ET, for more The enrollment form is available The enrollment form is available information. online at velcade.com/files/pdfs/ online at velcade.com/files/pdfs/ VELCADE_VRAP_Enrollment_ VELCADE_VRAP_Enrollment_ RapidStart Program Form.pdf. You can also obtain an Form.pdf. You can also obtain an If patients experience a delay in enrollment form by calling 1.866. enrollment form by calling 1.866. insurance coverage determination of VELCADE (1.866.835.2233), VELCADE (1.866.835.2233), at least 5 days, they may be eligible option 2, Monday through Friday, option 2, Monday through Friday, to receive a one-month supply 8:00 am to 8:00 pm ET. Fax

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 69 Takeda Oncology

completed forms to: 800.891.9843. Learn more online at velcade.com Patient Assistance Checklist for Medicare-Only Patients or by calling 1.866.VELCADE (1.866.835.2233) and choosing 3 I have received the chemotherapy order written by the physician? option 2. 3 I have verified the patient’s insurance coverage? 3 I have verified that the drug(s) are indicated for the patient’s diagnosis? 3 I have obtained prior authorization, if needed? 3 I have identified the patient’s responsibility (an estimate in dollars) 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

70 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 71 Tesaro

Tesaro, Inc.

Oncology-related products: Zejula® (niraparib) capsules

Patient and Reimbursement Assistance Website togetherwithtesaro.com

PATIENT ASSISTANCE (1.844.283.7276), Monday there is a coverage-related delay at through Friday, 8:00 am to 8:00 first dispense (Quick Start) or an TOGETHER with pm ET to learn more or begin the interruption in coverage for patients TESARO™ enrollment process. already on treatment (Bridge) so TOGETHER with TESARO is that treatment can start or continue a patient resource program that Commercial Co-pay according to the patient’s treatment provides medication access and Assistance Program plan. Terms and conditions apply. affordability services to patients The TOGETHER with TESARO The program covers up to 5 refills taking Zejula. Our expert case man- Commercial Co-pay Assistance pending resolution of related agement team facilitates a seamless Program may reduce out-of-pocket coverage delay. process to ensure that patients and costs for commercially insured providers get the individualized patients. The program reduces Patient Assistance support needed, including: co-pay and/or coinsurance to $0 Program • Benefits investigation with a $26,000 annual maximum. The Patient Assistance Program • Prior authorization and appeals The virtual card can be initiated and provides product to eligible support utilized by specialty pharmacies in uninsured and underinsured • Quick Start and Bridge Programs Tesaro’s limited distribution network patients who have demonstrated • Commercial Co-pay Assistance or in-office dispensing sites. financial hardship. This program Program supports eligible patients who have • Patient Assistance Program The Commercial Co-pay Assis- a household income up to 500% • Referrals to patient advocacy and tance Program is not retroactive. of the current Federal Poverty independent co-pay foundations. It can only be applied forward Level. Patient signature is required from the date of enrollment for on the Patient Consent for Patient There are three ways to enroll: 12 months and must be renewed a Assistance Program Form found at • Enroll your patient online by year after enrollment. Checks are togetherwithtesaro.com. going to togetherwithtesaro.com sent biweekly directly to healthcare and following the online portal providers. To enroll, visit activate TOGETHER with TESARO can instructions. thecard.com/tesaro. also refer patients to independent • Download the drug-specific co-pay foundations which can assist enrollment form, complete it, and Quick Start and Bridge patients in finding other sources fax it to 1.800.645.9043. Programs of financial support based on their • Contact a case manager Providers can prescribe a 15-day eligibility. For information, call (togetherwithtesaro.com/ supply of Zejula at no cost in the 1.844.2TESARO (1.844.283.7276), find-my-case-manager) event of an insurance coverage Monday through Friday, 8:00 am to or call 1.844.2TESARO delay. This will be provided only if 8:00 pm ET.

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 71 Tesaro

REIMBURSEMENT Patient Assistance Checklist for Medicaid Patients ASSISTANCE Benefits Investigation 3 I have received the chemotherapy order written by the physician? TOGETHER with TESARO provides a benefits investigation for 3 I have verified the patient’s insurance coverage? providers and patients at no cost. 3 I have verified that the drug(s) are indicated for the patient’s diagnosis? Once patient consent is obtained and the patient is enrolled in 3 I have obtained prior authorization, if needed? TOGETHER with TESARO, their case manager will look into specific 3 I have identified the patient’s responsibility (an estimate in dollars) coverage and benefits details and for treatment costs? provide providers with the results. The patient may also separately ask 3 I have met with the patient to assess his or her ability to pay for treatment? for a benefit investigation or receive 3 Based on this meeting, does patient need drug replacement? the requested results. q YES q NO

Prior Authorization and If yes, is a replacement drug program available? (Note: an appeal must to Appeals Support be made to receive drugs.) TOGETHER with TESARO offers q YES q NO prior authorization/precertification facilitation and appeals support for If yes, identify drug and program: denied claims. We cannot sign or submit prior authorizations or letters 3 Does the patient qualify for this program? of appeal on your behalf, but we can q YES q NO support providers in the process. If the provider chooses to handle these If no, state reason(s) why: independently, sample letters can be downloaded to assist in providing documentation and requests to the If yes, I have completed all the necessary forms and paperwork for the patient’s health plan. For more drug replacement. information, visit togetherwith q YES q NO tesaro.com or call 1.844.2TESARO If no, state reasons why: (1.844.283.7276), Monday through Friday, 8:00 am to 8:00 pm ET. 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

72 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 73 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 should be faxed to the number (1.888.587.3263) is a service provided at the top of the form. provided by Teva Oncology to The Teva Cares Foundation (NOTE: The fax number may differ help physicians and their patients The Teva Cares Foundation is a depending on the Teva medication.) understand the complexities of reim- conglomeration of Patient Assi- bursement and where CORE fits stance Programs designed to If your patient does not meet the in. Reimbursement consultants are improve patient access to Teva eligibility requirements for the available Monday through Friday, medications and ensure that cost is Teva Cares Foundation Patient 9:00 am to 8:00 pm ET, to provide not a barrier to care. Through these Assistance Programs, Teva may assistance with the following: programs, the Teva Cares Foun- offer a reimbursement assistance • Benefit verification and coverage dation is able to provide certain Teva program or other type of program determination medications at no cost to patients in to assist your patient. For more • Pre-certification and prior autho- the United States who meet certain information, please call 888.TEVA. rization support insurance and income criteria. USA (838.2872). Some patients may • Coverage guidelines and claims Eligibility is based on a patient’s be eligible for assistance from other investigation assistance income and prescription insurance programs. For a listing of these other • Personalized support through the status, and varies depending on assistance programs go to: tevacares. claims and appeals process the Teva medication that has been org/OtherResources.aspx. • Templates for letters of medical prescribed. To determine if your necessity patient qualifies, review the Teva REIMBURSEMENT • Referral to the appropriate Cares Foundation Patient Assistance ASSISTANCE Teva Cares Foundation Patient Programs eligibility requirements Assistance Program. online at: tevacares.org/DoIQualify. CORE aspx or call 877.237.4881, Monday CORE (Comprehensive Oncology Download the CORE enrollment through Friday, 9:00 am to 8:00 pm Reimbursement Expertise) provides form at: tevacore.com/PDF/ ET. Then download the appropriate patients and providers with a reim- Enrollment%20Form.PDF. Fax the enrollment application for the Teva bursement support program, as completed form to 866.676.4073. medication you have prescribed at: well as online tools to help make it Providers can also create an account tevacares.org/DownloadApplica easier to understand and navigate and enroll their patients online. tion.aspx. Completed applications reimbursement. The CORE Hotline

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 73 Foundation Medicine

Adaptive Biotechnologies

Oncology-related products: clonoSEQ® Assay (for the detection and monitoring of minimal residual disease in bone marrow samples from multiple myeloma and B-cell acute lymphoblastic leukemia patients)

Patient and Reimbursement Assistance Website clonoseq.com/adaptive-assist

PATIENT ASSISTANCE for enrollment, a patient must meet working days following receipt of all of the following criteria: your fully completed and signed Adaptive Assist™ application. An incomplete form Adaptive Biotechnologies under- • Be a U.S. citizen or legal resident may result in delays to processing stands that each patient’s situation aged 18 years or older. Patients and/or enrollment. is unique. We are committed to under the age of 18 are eligible, providing guidance and support but require the application form during each step of the insurance to be signed by a parent or legal process. That’s why we offer the guardian. Adaptive Assist program: to help • Be uninsured or have insurance facilitate access to clonoSEQ testing that does not cover the full cost of services for patients who could clonoSEQ testing. benefit from the clinical insights • Meet financial need requirements provided by next-generation mea- based on the patient’s income and surable residual (MRD) testing. the number of persons in their household. Have questions? Call the Patient • Submit a completed and Support Team at 1.855.236.9230, signed PFAP Application Form Monday through Thursday, 9:00 am (clonoseq.com/sites/default/files/ to 7:00 pm ET, and Friday, 9:00 am PM-US-CORP-0002.2_Adaptive_ to 5:00 pm ET, for answers to your PSP_ApplicationForm_WEB.pdf) questions about insurance, billing, including acknowledgment of payment, or financial assistance. Call the requirement to submit a tax the hotline to discuss your individual return, W-2, pay stub, or other circumstances and to see if you comparable document demon- might qualify. strating financial need if and when selected for participation in the Adaptive Biotechnologies is upfront enrollment audit. Submit committed to providing financial the completed and signed appli- assistance opportunities to qualified cation via email, fax, or mail. clonoSEQ patients with a demonstrated financial need and in In most cases, Adaptive Biotech- accordance with the terms of the nologies will send a notification Adaptive Patient Financial Assis- letter indicating your final program tance Program (PFAP). To be eligible eligibility determination within 10

74 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 75 Foundation Medicine

Foundation Medicine

Oncology-related products: FoundationOne® CDx (companion diagnostic for patients across all solid tumors), FoundationOne® Liquid (liquid biopsy test for solid tumors), FoundationOne® Heme (genomic profiling test for hematologic malignancies and sarcomas)

Patient and Reimbursement Assistance Website access.foundationmedicine.com/

PATIENT ASSISTANCE • Their testing is ordered by a treating physician. FoundationAccess™ Financial assistance may be available Note: If the patient are a Medicare/ for based on the patient’s financial Medicare Advantage customer, they situation. If the patient is uninsured may need to sign an Advance Benefi- or cannot afford the applicable ciary Notice (ABN) prior to the test out-of-pocket cost, contact the order. The physician will determine Client Services team, 888.988.3639, if an ABN is required. Monday through Friday, 8:00 am to 8:00 pm ET, with regard to Patients with Private Insurance eligibility. To apply for financial Foundation Medicine will work assistance or download a directly with insurance companies to paper application, visit try to obtain coverage. Depending access.foundationmedicine.com. on the terms of the insurance plan, the patient may have financial Patients with Medicare responsibility for co-pay, co-insurance, For many patients with advanced or deductible as directed by the plan. solid tumor cancer, FoundationOne CDx is covered by Medicare. If the If the insurance company denies patient is on Medicare and meets the coverage, with patient consent, we following criteria, they may not have will work on behalf of the patient to out-of-pocket expenses for their Foun- attempt to obtain coverage and will dationOneCDx solid tumor testing: work with the patient and doctor • The patient has either recurrent, in pursuing appeals to minimize the relapsed, refractory, metastatic, or financial burden. If the patient is advanced stages III or IV cancer. eligible for financial assistance, this • This is their first time having a is applied to their out-of-pocket cost. FoundationOne CDx test for this cancer diagnosis or have had a Foun- Note: If the patient has private/ dationOne CDx test before, but commercial insurance, a prior autho- this is a different type of cancer—a rization form may be required in “new primary” cancer diagnosis some cases. • They have decided to seek further cancer treatment such as therapeutic chemotherapy; and

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 75 ASSOCIATION OF COMMUNITY CANCER CENTERS

● ● ● ● ● ● ●

II CI I OA CA

T ultidisciplinary ultiple yeloma Care

Models of Effective Care Delivery This new publication offers a convenient summary of recent updates in the management of this heterogeneous disease, including ASSOCIATION OF COMMUNITY CANCER CENTERS ■ iagnostic Criteria by the International Myeloma orking roup MULTIDISCIPLINARY MULTIPLE ■ Revised International Staging System MYELOMA CARE ■ ● ● ● ● ● ● ● ASCO Clinical ractice uideline Update Role of Bone-Modifying

MODELS OF EFFECTIVE CARE DELIVERY Agents in Multiple Myeloma

lus, read how three cancer programsa community-based comprehensive program, an academic medical center, and an NCI-designated programare delivering multidisciplinary care

to this patient population.

Online Resource Center Regional Lecture Series Access a robust resource compendium comprised iew on-demand webinars that outline how to of multifaceted information to support your role effectively manage patients with high-risk proﬁ les in caring for patients with multiple myeloma. and the need for a team-based approach to care.

Access at accc-cancer.org/multiple-myeloma-care

● ● ● ● ● ● ●

In partnership ith unding and support is proided by

The Association of Community Cancer Centers (ACCC) is the leading education and advocacy organization for the multidisciplinary cancer team. ACCC is a powerful network of 2,000 cancer care professionals from 2,100 hospitals and practices

nationwide. ACCC is recognized as the premier provider of resources for the entire oncology care team. For more information visit accc-cancer.org or call 301.984.9496. Follow us on Facebook, Twitter, and LinkedIn, and read our blog, ACCCBuzz. 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 77 ASSOCIATION OF COMMUNITY CANCER CENTERS

Advance your delivery of patient-centered care with the HEALTH LITERACY GAP ASSESSMENT TOOL

Pinpoint where targeted health literacy efforts can lead to more effective communication in your cancer program.

ASSESS YOUR PROGRAM AT: accc-cancer.org/health-literacy

A full report will be emailed upon completion. All results are confidential.

WHY TAKE THE ASSESSMENT? ASSESSMENT DOMAINS INCLUDE: 1. Identify areas where simple quality • Health Literacy Program improvement measures will enhance • Staff Training patient-centered care. • Health Information 2. Understand if education efforts are effective for your patient population. • Navigation 3. Create a case for leadership on the need • Technology to ensure alignment to standards created • Quality Measurement and Improvement by the National Academy of Medicine (formerly, the Institute of Medicine). Access robust resources for each domain online.

Funding & support provided by

The Association of Community Cancer Centers (ACCC) is the leading advocacy and education organization for the multidisciplinary cancer care team. ACCC is a powerful network of 24,000 cancer care professionals from 2,100 hospitals and practices nationwide. ACCC is recognized as the premier provider of resources for the entire oncology care team. For more information, visit the ACCC website at accc-cancer.org or call 301.984.9496. Follow us on Facebook, Twitter, and LinkedIn, and read our blog, ACCCBuzz.

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 77 Other Patient Assistance Programs & Resources

Other Patient Assistance Programs & Resources

Agingcare.com® • In-home services Check: cancercare.org periodically agingcare.com • Taxes for funding updates. In order to • Transportation be eligible for financial assistance A web-based resource for care- • Employment training. patients must: givers, including the Prescription • Have a diagnosis of cancer Drug Assistance Program Locator: If patients have Medicare and have confirmed by an oncology agingcare.com/Articles/prescription- limited income and resources, they healthcare provider drugassistance-program-locator- may be eligible for the Medicare • Be in active treatment for cancer 171753.htm. This tool allows older Rx Extra Help program. Patients • Live in the U.S. or Puerto Rico adults and their families to search may be able to get extra help pay- • Meet our eligibility guidelines for financial aid programs for ing for prescription drug costs if: based on the Federal Poverty Limit prescription medications. Search • Their income is below $18,210 if for prescription drug assistance plans single or $24,690 if married Here’s how to apply: by state or medication name • Their combined savings, invest- 1. Call 800.813.HOPE (4673) or browse a list of nationwide ments, and real estate are not and speak with a CancerCare non-profit prescription drug assis- worth more than $14,100 if single social worker to complete a tance programs. or $28,150 if married (see online brief interview, Monday through for exclusions). Thursday, 10:00 am to 6:00 pm BenefitsCheckUp® ET, and Friday, 10:00 am to 5:00 benefitscheckup.org If patients meet the guidelines, they pm ET. will have low or no deductibles, 2. If patients are eligible to apply, A free service of the National low or no premiums, no coverage we will: Council on Aging (NCOA), a non- gap, and will pay much less for • Mail the patient an profit service and advocacy organi- prescriptions. At the same time, individualized barcoded zation. Many adults over 55 need patients can start the application application help paying for prescription drugs, process for the Medicare Savings • Request documentation to healthcare, utilities, and other basic Program. Patients will also find out verify the patient’s income. needs. There are over 2,500 federal, if there are other benefits programs 3. Patients must submit a com-pleted state, and private benefits programs that can save them money. Apply application. Here are some tips: available to help. BenefitsCheckUp online at: benefitscheckup.org/ • Print clearly—illegible appli- asks a series of questions to help medicare-rx-extra-help- cations cannot be processed. identify benefits that could save pa- application-welcome. • Fill in each blank space tients money and cover the costs of in the application. Use “no,” everyday expenses. After answering the CancerCare® “none,” or “0” as questions, patients receive a per- cancercare.org appropriate—do not leave sonalized report that describes the any blank responses. programs that may help them. CancerCare provides limited • Have a medical oncology Patients can apply for many of the finan-cial assistance to people healthcare provider complete programs online or print an appli- affected by cancer. As a non-profit all sections of the Medical cation form. Here are the types of organization, funding depends on Information Section and expenses patients may get help with: the sources of support CancerCare provide a signature and date. • Medications receives at any given time. If Patients cannot complete this • Food CancerCare does not currently section. • Utilities have funding to assist you, their • Legal professional oncology social workers • Healthcare will always work to refer you to • Housing other financial assistance resources.

78 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 79 Other Patient Assistance Programs & Resources

• Make sure patients use the to provide co-payment assistance, CCAF, as the company may offer correct CancerCare mailing however, they will refer patients to a program that can help. Patients address and fax number other organizations that may be able who are uninsured (do not have listed on the application. to help. any insurance or medical plan that covers their prescription medicines), NOTE: CancerCare’s financial assi- To qualify for assistance, patients are not eligible for co-payment stance does not cover basic living must meet the criteria below: assistance. However, we encourage expenses such as rent, mortgages, • Financial. Individuals or families you to contact us at: 866.55.COPAY utility payments, or food. with an adjusted gross income (866.552.6729), Monday through of up to four or five times the Friday, 9:00 am to 7:00 pm EST, CancerCare® Co-payment Federal Poverty Level may qualify and Friday, 9:00 am to 5:00 pm EST, Assistance Foundation for assistance. CCAF may also so that we can refer you to other cancercarecopay.org consider the cost of living in a organizations or patient assistance particular city or state. Income programs. CancerCare Co-payment Assistance verification is required as part of Foundation (CCAF) helps people the application process. Eligible individuals will receive an afford the cost of co-payments • Medical. Patients must be application packet with instructions for chemotherapy and targeted diagnosed with one of the cancer on how to apply for assistance. treatment drugs. This assistance is types covered by CCAF (check the Co-payment specialists are available provided free of charge to ensure CCAF website for an up-to-date to answer questions about this patient access to care and com- list of the types of cancers for process. Or patients can enroll pliance with prescribed treatments. which assistance is currently online at: portal.cancercare CCAF offers a seamless, same- available). Patients must sign and copay.org. day approval process through a attest that their primary diagnosis state-of-the-art online platform. matches our fund, and additional Cancer Financial Patients will always know if documentation may be requested Assistance Coalition they have been approved on the by the prescribing physician on a cancerfac.org same day they apply. This allows case-by-case basis. Patients must immediate access to the full array currently be undergoing chemo- CFAC is a coalition of financial of CancerCare support services, therapy or prescribed and/or using assistance organizations joining including telephone, online, and a targeted treatment drug when forces to help cancer patients expe- in-person counseling, support they apply to CCAF. rience better health and well-being groups, information and resource • Insurance. Patients must have by limiting financial challenges, referrals, publications, education, insurance that covers a portion through: and financial assistance with of their medications. Some 1. Facilitating communication and treatment-related expenses such as funds are restricted to assist collaboration among member transportation and child care. only those covered by a federal organizations health insurance program 2. Educating patients and providers In order to be eligible for assistance, such as Medicare, Medicaid, about existing resources and patients must complete and sign or TRICARE, while others linking to other organizations that an application and HIPAA Authori- accept both private and federal can disseminate information about zation form, as well as provide insurance. the collective resources of the proof of income. CCAF will review • Other criteria. Patients must be member organizations applications and forms on a receiving treatment in the United 3. Advocating on behalf of cancer first-come, first-served basis to the States. Patients must be a U.S. patients who continue to bear extent that funding is available. citizen or legal resident. financial burdens associated with the costs of cancer treatment and NOTE: as a non-profit organi- NOTE: If patients have private care. zation, CCAF cannot guarantee that insurance, please contact the drug funding will always be available company that manufactures their Because CFAC is a coalition of for a particular diagnosis. If unable medication before you contact organizations, it cannot respond

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 79 Other Patient Assistance Programs & Resources

to individual requests for financial number in the household. convenient mobile app. Patients, assistance. To find out if financial healthcare providers, and pharma- help is available, use the CFAC NOTE: Patients will be informed cists can use FamilyWize to ensure database at: cancerfac.org. Search by immediately upon application if they the lowest possible price for a pre- cancer diagnosis or specific type of qualify for assistance. scription medication is paid at the assistance or need (i.e., general living counter. expenses, transportation, childcare). The CPR Program offers four points of entry: With the Drug Price Look-up Tool Co-Pay Relief 1. Patients may apply via the Patient (familywize.org/drug-price-look- copays.org Online Application Portal (copays. up-tool), patients can enter the org/patients) available 24 hours name of their drug and ZIP code The Patient Advocate Foundation a day. and see the price they’ll pay using (PAF) Co-Pay Relief Program (CPR) 2. Medical providers may apply FamilyWize at local pharmacies. provides direct financial support to on behalf of their patients via Discounts are available only at par- qualified patients, including those the Provider Online Application ticipating pharmacies. insured through federally-administered Portal (copays.org/providers) health plans such as Medicare, available 24 hours Prescription drug discount card must assisting them with prescription a day. be presented with prescription to a drug co-payments, co-insurance, and 3. Pharmacies may apply on behalf participating pharmacy to obtain deductibles required by the patient’s of their patients via the Pharmacy the discount price. Pricing is always insurer. CPR call counselors work Online Application Portal (copays. the lesser of the discounted price directly with the patient as well as org/pharmacy) available 24 hours or pharmacy’s retail price. If the with the provider of care to obtain a day. pharmacy’s price is less, there is no necessary medical, insurance, and 4. The program offers personal discount. Cannot be used with other income information to advance the service to all patients through the prescription cards. All benefits are application quickly. Upon approval, use of an Approval Specialist, per- subject to change without notice. payments may be made to: sonally guiding patients through Some restrictions apply. • The pharmacy the enrollment process toll free at • The healthcare provider 866.512.3861, Option 1. Learn more at familywize.org, or • The patient directly. call 800.222.2818. FamilyWize® Eligibility requirements: familywize.org Good Days® • Patients must be insured and mygooddays.org insurance must cover the med- Since 2005, FamilyWize has offered ication for which they seek a free prescription discount program Good Days is here to help: helping assistance. for patients nationwide, saving overcome the burden of treatment • Patients must have a confirmed money on prescription drugs that costs, connecting patients to a diagnosis of the disease or illness are excluded by insurances plan or community that cares. Good Days for which they seek financial that are not covered because patients not only make life-saving and assistance. have exceeded their insurance plan’s life-extending treatments affordable; • Patients must reside and receive maximum limits. Through partner- they act as patient advocates, helping treatment in the United States. ships with major and regional chain them navigate the system and guiding • The patient’s income must fall pharmacies, FamilyWize negotiates them to additional emotional support below the income guidelines of discounted prices on all FDA-ap- through foundations and other the fund under which they are proved prescription medications. organizations dedicated to those with requesting financial assistance. All specific, life-altering conditions. funds have income guidelines of The free FamilyWize Prescription either 300 percent, 400 percent, Discount Card (familywize.org/ Good Days covers what insurance or less of the Federal Poverty free-prescription-discount-card) won’t—the costly co-pays for drugs Guideline with consideration of never expires and is available and treatments that can extend the Cost of Living Index and the both as a physical card and as a life and alleviate suffering. Good

80 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 81 Other Patient Assistance Programs & Resources

Days also has a premium assistance To be eligible, patients must meet • Patient contact, household program for patients with a qualified certain criteria: income, and insurance diagnosis who need help paying • HealthWell must have a disease information their monthly medical insurance fund that covers the patient’s • Specific disease, treatment, and premiums. Their Travel Concierge illness, and their medication must physician information, including Program helps those eligible with be an eligible treatment under that the office fax number everything from air travel to illness • Type of assistance requested overnight stays to parking, when • Patients must have some form of (co-pay or premium) medically necessary as determined health insurance such as private by prescribing physicians. insurance, Medicare, Medicaid, or If approved, HealthWell allocates TRICARE each patient a grant for a rolling Good Days has streamlined the • Patients have incomes up to 400% 12 months, after which patient or enrollment process so patients can or 500% of the federal poverty provider may reapply as long as receive immediate determination of level (HealthWell considers funding is available. Grant amounts eligibility for financial assistance. household income, the number vary by disease state. Patients will Eligibility criteria: in the household, and the cost of receive a HealthWell Pharmacy • Patient must be diagnosed with a living in the patient’s city or state) Card and a Reimbursement Request covered disease and program must • Patient must be receiving Form. Patients can use reim- be accepting enrollments treatment in the United States. bursement forms in cases where they • Patient must have a valid Social cannot use their pharmacy card. Security number to apply for assis- With the patient’s permission, Patients must use their grant at least tance and receive treatment in the providers, pharmacy representatives, once every 120 days to keep their United States and patient advocates grant active. There are no restric- • Patient must be seeking assistance can apply on behalf of a patient tions on the provider or pharmacy for a prescribed medication that in two ways: a patient selects. Patients are free to is FDA approved to treat the 1. Apply online using the change medications, providers, or covered diagnosis HealthWell provider portal at: pharmacies at any time, as long as • Patient is required to have valid https://healthwellfoundation.secure. the eligibility criteria continues to insurance coverage force.com/ be met. Patients can change assis- • Patient income level must be at 2. Apply by phone at 800.675.8416, tance type—co-pay to premium or below 500% of the Federal Monday through Friday, 9:00 am or premium to co-pay—one time Poverty Level (FPL). to 5:00 pm ET. during their enrollment period.

To enroll, go to mygooddays.org/ NOTE: Providers, pharmacists, All patients who have been approved apply and either apply online or and social workers are strongly for a grant are subject to an income download the English and Spanish encouraged to use the Provider documents review. During the review enrollment forms and fax completed Portal to apply so that patients can process, the patient’s grant will forms to 214.570.3621. readily access HealthWell hotline be temporarily inactive until their care managers. income has been verified. HealthWell Foundation® healthwellfoundation.org Before beginning the application For more detailed information on process, be sure to contact the reimbursement guidelines and The HealthWell Foundation reduces company that makes the medication practices, and to download important financial barriers to care for under- the patient needs. Manufacturers reimbursement and income verification insured patients with chronic or have generous assistance programs forms, go to healthwellfoundation. life-threatening diseases by providing that exceed what most non-profit org/how-to-get-reimbursed/. financial assistance to eligible individuals foundations can offer, particularly to cover the cost of co-insurance, for commercially insured patients. Questions? Call 800.675.8416 co-payments, healthcare premiums, to speak with a HealthWell repre- and deductibles for certain medica- Here’s what is needed to complete sentative, Monday through Friday, tions and therapies. the application: 9:00 am to 5:00 pm EST.

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 81 Other Patient Assistance Programs & Resources

The Leukemia & personalized service throughout the 2. Click on the name of your Lymphoma Society application process. medicine to find out if there is a lls.org Patient Assistance Program (PAP) Patient Aid Program available. If there is an active The Leukemia & Lymphoma Society program available, a PAP icon will (LLS) Co-Pay Assistance Program The Patient Aid Program provides appear under the drug name. helps patients pay their insurance financial assistance to blood cancer 3. Click on the PAP icon to access premiums and meet co-pay obliga- patients in active treatment. Eligible the eligibility and contact infor- tions. LLS can also help providers patients will receive a one-time $100 mation for the program(s). In and patients find additional sources stipend to help offset cancer related some cases, the program appli- of financial support. The LLS expenses. Program continuation cation form can be printed Co-Pay Assistance Program offers is dependent on the availability of from the NeedyMeds website. financial help toward: funds and the program could be Applications should be faxed or • Blood cancer treatment-related modified or discontinued at any time mailed directly to the PAP, not to co-payments if funding is limited or no longer NeedyMeds. • Private health insurance premiums available. To be eligible, patients 4. PAPs can also be found by • Medicare Part B, Medicare must: searching the Program Name Plan D, Medicare Supple- • Be a United States citizen or List OR by looking through the mentary Health Insurance, permanent resident of the U.S. or Company Name List, both found Medicare Advantage premium, Puerto Rico under the “Patient Savings” tab Medicaid spend-down, or co-pay • Have a blood cancer diagnosis on the NeedyMeds website. obligations. • Be in active treatment, scheduled 5. If an application form is available to begin treatment, or being through a PAP, look for it in the To be eligible for Co-Pay Assistance, monitored by their doctor. Program Applications list. Look patients must: for all of your medications, not 3 Have a household income at or Apply online at unpportal.lls.org just the most expensive ones. below 500 percent of the U.S. or by phone at 866.446.7377, Federal Poverty Guidelines as Monday through Friday, 8:30 am Applications Assistance: adjusted by the Cost of Living to 5:00 pm ET. If you need help filling out your Index applications, see our list of orga- 3 Be a United States citizen or NeedyMeds nizations that provide application permanent resident of the U.S. or needymeds.org assistance for free or a small fee Puerto Rico and be medically and here: www.needymeds.org/local- financially qualified NeedyMeds is a non-profit infor- programs. These organizations can 3 Have medical and/or prescription mation resource dedicated to helping help with such things as finding a insurance coverage people locate assistance programs program for your prescription med- 3 Have an LLS Co-Pay Assis- to help patients afford their medi- ication, completing the application tance Program–covered blood cations and other healthcare costs. forms, and working with physicians cancer diagnosis confirmed Each program has its own quali- who must sign the forms. You can by a provider (See a list of fying criteria. To find a PAP that find local programs in two ways: covered diagnoses here: lls. you may qualify for click on the 1. Enter the patient’s ZIP code to org/support/financial-support/ brand name or generic name drug find a program in their area or co-pay-assistance-program). under the “Patient Savings” tab on 2. Search by state. the NeedyMeds website, or search Apply online at: cprportal.lls.org/ for your medication name using the If your medicine does not appear on search feature in the upper lefthand the brand name or generic name lists, You can also apply or get more corner of the screen. If using the then it is not available through a PAP. information about the LLS Co-Pay “Patient Savings” tab: Other assistance options include: Assistance Program by calling 1. Click on the first letter of the • Coupons, Rebates & More are 877.557.2672 and speaking with a name of your medicine in the offered by various drug companies co-pay specialist who will provide alphabet bar. and may offer a rebate, discount,

82 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 83 Other Patient Assistance Programs & Resources

or even free trial size of a med- for assistance are by looking for the search is complete you can add ication. Offers for prescription programs that serve a specific geo- one or more prescription drugs from medications require a doctor’s graphical area. If you know the your search to the My Medicines prescription. Offers can be found name of a specific program about list, which appears on the right side three ways: under Brand Name which you want more of the page. Repeat this process until Drugs (if a coupon icon appears information, you can also search you have entered and selected all of under the drug name, click on the by name of program. the medicines. icon). They can also be found on the Coupons, Rebates & More Assistance with Step 2. Tell us about your patient. page of the NeedyMeds website; Government Programs: Provide basic information about use the alphabet bar to find the Every state has programs to help the patient and the type of drug medicine. Or do a category search needy families and individuals with coverage (if any) he or she currently for coupons by diagnosis or the cost of healthcare. NeedyMeds has. Answer short questions, such symptoms. has compiled a database of these as the patient’s residency, age, and • NeedyMeds Drug Discount Card state programs. The programs household income, to see which provides savings of up to 80% on are available via the organization patient assistance programs they many prescription medications. website. You can search these may qualify for. You must answer The card is free and available to programs by clicking on a state, the all questions marked with an everyone. There is no registration District of Columbia, Puerto Rico, or asterisk on this page for yourpatient and your entire family can use the Guam. Programs and their guidelines to be considered. If you need same card. The card cannot be used vary from state to state. NeedyMeds assistance, please visit pparx.org/ in combination with any insurance. also has a list of Medicaid sites where wizard-help or call 1.888.4PPA. Download a card and learn more you can learn more about Medicaid NOW (1.888.477.2669). about its benefits at www.needymeds. in your state, as well as general org/drug-discount-card. Information information on Medicaid. Step 3. Get your patient’s results. on other drug discount cards are also See which prescription assistance available on the NeedyMeds website. For all questions, call programs your patient may be • Diagnosis-Based Assistance: 1.800.503.6897, Monday through eligible for and select the ones you There are many government and Friday, 9:00 am to 5:00 pm ET or would like to apply to. privately-funded programs that email [email protected]. help with costs associated with a Step 4. Complete the application specific diagnosis. They may cover Partnership for process. Print, complete, and mail many types of expenses, including Prescription Assistance applications to each program your drugs, insurance co-pays, office pparx.org patient is applying to. You may visits, transportation, nutrition, download the applications directly medical supplies, child, or respite The Partnership for Prescription from your computer or device or care. Some cover one specific Assistance (PPA) helps qualifying have them emailed to you. diagnosis, while others cover uninsured and underinsured patients whole categories (such as all types connect to the right assi-stance PPA offers other resources, including: of cancers) or even all chronic programs so that they can get the • Searchable list of Patient Assistance medical illnesses. Some programs medicines they need for free or Programs: pparx.org/prescription_ are national in scope, while others nearly free. The Partnership for assistance_programs/list_of_ are limited to people in specific Prescription Assistance will help participating_programs states. Most have some type of you find the program that’s right for • A list of discount drug card eligibility requirements, usually your patient, free of charge. programs at: pparx.org/prescription_ financial ones. NeedyMeds has assistance_programs/savings_cards compiled a database of diagno- Step 1. Tell us what medicines your • Information about Medicare sis-based assistance programs that patient takes. Go to: pparx.org/ prescription drug coverage at: you or your patient can search. gethelp/select-therapies. Type the pparx.org/prescription_ It’s best to search by the type of name of the medicine into the box assistance_ programs/ diagnosis. Other ways to search and click the search button. Once medicare_drug_coverage.

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 83 Other Patient Assistance Programs & Resources

Have recent natural disasters Step 1. Log into the correct Pan Case management services: Profes- affected your patient’s ability to Foundation Portal (i.e., “Provider sional case managers at PAF work get access to their prescription Portal,” “Patient Portal,” or with the mission to identify and medicines? Download the natural “Pharmacy Portal”) to begin the reduce the challenges that indi- disaster worksheet: pparx.org/sites/ application process. viduals have when seeking care for default/files/NATDISLTR.pdf and their disease. Case management PPA may be able to match your Step 2. Select the appropriate disease services are available on behalf of patient with a program to help them fund for your patient. Select your patients meeting all of the following regain access to their medicines. patient’s primary insurance type from criteria: the drop-down list. Then, select the • Have a confirmed diagnosis of a Patient Access Network name of the medication for which chronic disease, a life-threatening Foundation you are applying for assistance. disease, or debilitating disease, panfoundation.org or be seeking screening services Step 3. You will need to access the related to symptoms or suspicion The Patient Access Network following information: of a chronic, life-threatening, or Foundation (PAN) facilitates • Diagnosis and medication name debilitating disease access to medical treatment for • Demographics: Name, address, • Be in active treatment, had federally or commercially insured phone number, email address, and treatment within the past 6 patients with chronic, rare, or Social Security Number months, or going into treatment in life-threatening illnesses. Providers • Income: Adjusted gross income the next 60 days and their patients can apply for applicable to the patient and • Be a U.S. Citizen or Permanent assistance by calling 1.866.316.7263 all members of the patient’s Resident of the U.S. or online through the Pan Foun- household • Be receiving treatment at a facility dation Provider Portal: • Insurance: Health insurance and in the United States or one of its providerportal.panfoundation.org/. pharmacy card(s) US territories. • Physician demographics: In order for patients to qualify for Prescribing physician’s name, To connect with case management co-payment assistance with the phone number, and facility services, call 1.800.532.5274 or Patient Access Network Foundation, address. apply online at https://www.patient they must meet the following eligi- advocate.org/connect-with-services/ bility criteria: Step 4. Review the application to case-management-services-and- • Patient must be getting treatment make sure the information entered medcarelines/. for the disease named in the assis- is correct and then submit the tance program to which he or she application online using the PAN MedCareLine: A division of PAF, is applying Foundation Portal. For more infor- the MedCareLine’s team of pro- • Patient is insured and insurance mation or to apply over the phone fessional case managers assist with covers the medication for which call 1.866.316.7263. disability, health insurance navi- the patient seeks assistance gation including prior authorization, • The medication or product must Patient Advocate appeals for denied services, second be listed on PAN’s list of covered Foundation opinion options and screening for medications patientadvocate.org clinical trials. The case managers • Patient’s income must be below also assist patients who are expe- a designated percentage of the The Patient Advocate Foundation riencing financial challenges that Federal Poverty Level, depending (PAF) is a national non-profit charity are impacting their ability to pay on individual fund requirements that provides direct services to patients for care and basic cost of living • Patient must reside and receive with chronic, life-threatening, and expenses like housing, utilities, food, treatment in the United States or debilitating diseases to help access and transportation, researching and U.S. territories. (U.S. citizenship is care and treatment recommended by linking them to available financial not a requirement.) their doctor. It offers the following support programs that may meet services: some of these needs. Uninsured patients are also supported by

84 ASSOCIATION OF COMMUNITY CANCER CENTERS 2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 85 Other Patient Assistance Programs & Resources

the program with direct support news, and articles so that health patient assistance online system, in accessing public programs, care professionals and patients can each staff person must set up a health insurance enrollment, and find the information they need in separate account.) To set up your charity care that will allow access one place. Go to rxassist.org/search free account and place orders online to necessary care. For more infor- and search by either drug name or the following criteria are required: mation, visit patientadvocate.org/ company name. • You must be a healthcare provider connect-with-services/case-manage or their staff ment-services-and-medcarelines. If an application is available online, • A valid state license number for you can either open (download) the healthcare provider Co-Pay Relief Program: The PAF the application, type information • An email address (this will become Co-Pay Relief Program, one of the directly onto the application on your login) self-contained divisions of PAF, the screen and print it out, or print • The medication for which the provides direct financial assistance out the application and fill it out patient is applying to insured patients who meet certain by hand. If there is no application • The patient’s first and qualifications to help them pay for online, use the phone number last name. the prescriptions and/or treatments provided at the top of the Program Once you have the above information they need. This assistance helps Details page to call the company available, go to: rxhope.com/Prescriber/ patients afford the out-of-pocket for information on how to get an Register.aspx and follow the instruc- costs for these items that their application. tions. You will be setting up your insurance companies require. For free account and creating an order more information, visit copays.org. RxAssist Prescription Savings for your patient all at the same time. Card Financial Aid Funds: This inde- With the RxAssist Prescription Rx Outreach® pendent division of Patient Advocate Savings Card, patients can save up rxoutreach.org Foundation provides small grants to 85 percent where they already to patients who meet financial fill their prescription. Savings are Rx Outreach is a fully-licensed and medical criteria. Grants are possible with insurance, and there is non-profit mail order pharmacy provided on first-come first-served no additional cost to use the card. that ships medication directly to basis and are distributed until funds The card is active for immediate use patients’ homes. To make this are depleted. Qualifications and by patients, family, and friends. Visit process simple and cost-effective, processes for each fund may differ rxassist.org/coupon/generic?type= Rx Outreach typically ships a 90 based on fund requirements. Patients patients, call 877.537.5537, or or 180-day supply of the needed who are interested in applying for email [email protected] for more medication. Patients who meet financial assistance should start information. eligibility requirements can use Rx by calling this division toll free at Outreach regardless of whether they 855.824.7941 or by registering RxHope™ use Medicare, Medicaid, or other your account and submitting an rxhope.com health insurance. To be eligible to application online at financialaid. use Rx Outreach, patients must meet patientadvocate.org. Healthcare providers and their staff income requirements, which can can set up accounts online to order be found online at rxoutreach.org/ Questions? Call 1.800.532.5274, free medications for their patients find-out-if-you-are-eligible. Monday through Thursday, 8:30 am through the RxHope automated to 5:00 pm ET, and Friday, 8:30 am patient assistance online system. Providers and patients can enroll to 4:00 pm ET. If you would like to create a free in the program by following the account for one healthcare provider, steps below: RxAssist visit: rxhope.com/Prescriber/Set 1. Determine patient eligibility using rxassist.org upAccount.aspx. (NOTE: Each criteria above. account is valid for use by one 2. See if the patient’s drug is RxAssist offers a comprehensive healthcare provider only. If multiple listed on the RxOutreach database of these patient assistance members of your office staff wish Medication’s List: rxoutreach.org/ programs, as well as practical tools, to utilize the RxHope automated find-your-medications.

2019 PATIENT ASSISTANCE AND REIMBURSEMENT GUIDE 85 Other Patient Assistance Programs & Resources

3. Create a simple account by 5. The patient should receive a providing your email address and prescription for a 180-day supply selecting a password. Verify the with one refill or a 90-day supply email address provided. with three refills. The patient can 4. Enroll in Rx Outreach. To provide payment by credit or debit enroll, you’ll need to provide the card online or by phone, or check following information: or money order sent in the mail. • Name and contact infor- 6. Fax the prescription and appli- mation for provider and cation to 1.800.875.6591 or mail patient it to Rx Outreach, PO Box 66536, • Patient date of birth St. Louis, MO, 63166-6536. • Information on patient allergies and current If you have any questions, call medications 1.888.RXO.1234 (1.888.796.1234), • Patient income and Monday through Friday, 7:00 am to household size 5:30 pm CST, or email questions@ • For faster service, you can rxoutreach.org. include credit card information for payment at this time.

Tips for Assisting Patients in Applying to Patient Assistance Programs

3 If you have any questions, call the program directly. Eligibility requirements, drugs, dosages, even programs, change regularly so it’s best to go directly to the program for information. If you do not qualify for the PAP but cannot afford your medicine, tell the representative. Some companies may make hardship exceptions and are willing to review sit- uations on a case-by-case basis. Sometimes you can write an appeal letter to the program explaining your financial hardship.

3 Review the Federal Poverty Guidelines and Percentages over the Poverty Guidelines when looking at the eligibility guidelines of a program.

3 Fill out as much information on the application as possible, including the doctor’s address and phone number. Highlight the directions for the doctor and where he or she needs to sign. Give the doctor’s office an addressed-and stamped-envelope to send in the application or highlight the fax number so it is easy to find.

3 Plan ahead so your medicine supply doesn’t run out. When sending in an application, pay attention to the refill process and the amount of allowable refills. Each program is different; some require a call from the doctor’s office while another may allow the patient to call directly for a refill; others may require a new application, which takes time.

3 Be neat and complete. The directions on the application should be completed exactly as directed. Print neatly. If something is unreadable or there is a blank, then the application may be denied, which can delay the process of receiving the medicine. Put “N/A” or “not applicable” in blanks that are not filled out to indicate the material was read through and not skipped over. Include supplementary forms if requested. Make sure all accompanying photo- copies are clean and readable.

Source. ACCC Financial Advocacy Network. accc-cancer.org/FAN ASSOCIATION OF COMMUNITY CANCER CENTERS

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The Association of Community Cancer Centers (ACCC) is the leading education and advocacy organization for the multidisciplinary cancer team. ACCC is a powerful network of 25,000 cancer care professionals from 2,100 hospitals and practices nationwide. ACCC is recognized as the premier provider of resources for the entire oncology care team. For more information visit accc-cancer.org or call 301.984.9496. Follow us on Facebook, Twitter, and LinkedIn, and read our blog, ACCCBuzz.

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