P.O. Box 5670, Louisville, KY / BUSPAF ( )

Transcription

1 Applicatin Bayer understands that smetimes peple face financial challenges, and we are here t help. The Bayer US Patient Assistance Fundatin is a charitable rganizatin that helps eligible patients get their Bayer prescriptin medicine at n cst. Hw d I knw if I may be eligible? Yu may be eligible fr the Bayer US Patient Assistance Fundatin free drug prgram if yu: Live in the United States r Puert Ric Meet certain incme limits Dn t have insurance, r yur Bayer prescriptin medicine is nt cvered Hw d I apply? Cmplete and sign the Patient Infrmatin Sectin (pages 2-5). A caregiver can als cmplete this prtin f the frm Ask yur dctr r healthcare prfessinal (HCP) t cmplete and sign the Healthcare Prfessinal Sectin (page 6) Make a cpy f the cmpleted, signed applicatin fr yur recrds. Als, make a cpy f yur financial dcumentatin t send with yur applicatin Fax r mail the cmplete applicatin with a cpy f financial dcumentatin fr review by the prgram Where d I send my cmpleted applicatin? The cmpleted and signed applicatin with financial dcumentatin can be submitted by fax r mail: Fax: Mail: Bayer US Patient Assistance Fundatin P.O. Bx 5670, Luisville, KY Yur applicatin can nly be reviewed if it is cmpletely filled ut, signed by bth yu and yur dctr, and has the financial dcumentatin requested. Use the checklist n page 7 f this applicatin t make sure all infrmatin is included. / 1

2 Patient Infrmatin Sectin (T be cmpleted by the patient r caregiver) The Patient Infrmatin Sectin can be cmpleted by yu r a caregiver. Yur applicatin cannt be cnsidered withut a fully cmpleted and signed frm. If yu have questins, call BUSPAF ( ). Yur Medicatin(s) The fllwing Bayer prescriptin medicines are included in this prgram; please check all items yu are applying fr: Adempas (riciguat) Aliqpa (cpanlisib) Angeliq (drspirenne and estradil) Betasern (interfern beta-1b) Biltricide (praziquantel) Climara PRO (estradil, levnrgestrel transdermal) Jivi antihemphilic factr (recmbinant) PEGylated-aucl Kgenate Antihemphilic Factr (recmbinant) Kvaltry Antihemphilic Factr (recmbinant) Kyleena (levnrgestrel-releasing intrauterine system) Menstar (estradil transdermal system) Mirena (levnrgestrel-releasing intrauterine system) Natazia (estradil valerate and estradil valerate/diengest) Nexavar (srafenib) Safyral (drspirenne/ethinyl estradil/levmeflate) Skyla (levnrgestrel-releasing intrauterine system) Stivarga (regrafenib) Vitrakvi (lartrectinib) Yur Name and Cntact Infrmatin Name Date f birth / / First Last Day Mnth Year Male Gender Female Mailing address City State Zip cde Preferred cntact Hme Cell Wrk Preferred cntact time Mrning Afternn Yur address Yur Husehld Incme Hw many peple live in yur husehld and are dependent n yur husehld incme (include yurself)? Fr example: yu (1) + yur spuse (1) + yur children (2) + yur parents (2) = 6 What is yur ttal husehld incme? $ This includes all incme made by yu and yur relatives living in yur husehld. Please include incme earned by wrk wages, Scial Security retirement benefit, Scial Security disability benefit, unemplyment, any pensins, and any ther incme including alimny and child supprt. Adding all f these numbers tgether gives yur ttal husehld incme. Yu are required t submit prf f incme, which includes any f the fllwing (check all that apply): Recent 1040 r 1040EZ federal tax return 1099 tax frm Wage/tax statements (W2) Prf f nn-filing letter if yu did nt file a federal tax return / 2

3 Yur Healthcare Insurance Infrmatin D yu have healthcare insurance? Yes N If yes, please cmplete all sectins belw that apply. Yur Primary Healthcare r State/Gvernment Insurance Insurer name Plan name Plan phne number ( ) Name f plan subscriber Subscriber relatinship t patient Membership ID/plicy # Grup # Type: Cmmercial/Private Medicare Medicaid Veterans Affairs/Dept. f Defense State Elderly Drug Assistance State Children s Health Insurance Other Yur Secndary Healthcare Insurance (supplemental) If yu d nt have any ther insurance, yu d nt need t fill ut this sectin Insurer name Plan name Plan phne number ( ) Name f plan subscriber Subscriber relatinship t patient Membership ID/plicy # Grup # Type: Cmmercial/Private Medicare Medicaid Veterans Affairs/Dept. f Defense State Elderly Drug Assistance State Children s Health Insurance Other Yur Pharmacy Insurance (cmmercial r Medicare Part D prescriptin cverage) Insurer name Plan name Plan phne number ( ) Membership ID/plicy # Grup # Type: Cmmercial/Private Medicare Part D Name f plan subscriber Subscriber relatinship t patient / 3

4 By applying fr the Bayer US Patient Assistance Fundatin free drug prgram, I understand and agree: that: There is n charge t participate and my participatin in the prgram is nt cntingent n any requirement t purchase r use any Bayer prduct. Cmpleting and signing the prgram applicatin des nt guarantee my eligibility. The prgram may change r end at any time. I will nt sell r trade any medicine that I get thrugh this prgram. I will ntify the prgram within thirty (30) days if there is any change in my incme, health insurance, eligibility t enrll in Medicare Part D, r any ther reasn that may affect my eligibility. I will nt seek t be reimbursed r receive credit frm my insurance prvider, including Medicare Part D plans, fr medicine I receive thrugh the prgram. I will nt seek credit fr medicine frm the prgram tward my true ut-f-pcket expenses under Medicare Part D. The infrmatin I prvided in this applicatin is crrect and cmplete. I am prviding written instructins under the Fair Credit Reprting Act t the prgram, including its agents, administratrs, and service prviders, authrizing the prgram t btain infrmatin frm my credit prfile and/r ther infrmatin frm Experian Health. I authrize the Bayer US Patient Assistance Fundatin, including its agents, administratrs, and service prviders, t btain such infrmatin slely t determine my eligibility t participate in the prgram. Patient/Representative Signature / / Day Mnth Year Date (required) Check pint! Yu are almst dne. Please review the infrmatin, sign, and date n the fllwing page. / 4

5 Patient authrizatin t share health infrmatin I agree t allw my healthcare prviders and health insurers t give the Bayer US Patient Assistance Fundatin free drug prgram, Bayer and its agents my persnal and medical infrmatin, including healthcare cnditin, diagnsis and medicines, fr the purpses listed belw: (i) Determine if I am eligible fr the prgram, (ii) prvide me with free medicine thrugh the Bayer US Patient Assistance Fundatin free drug prgram if I am eligible t participate, and (iii) cmply with any laws that may require the use r disclsure f my infrmatin. Cntact me r my healthcare prvider fr additinal infrmatin t evaluate any adverse event r prduct cmplaint that I reprt r that my prvider reprts n my behalf. Cntact me t ask fr feedback n the quality r custmer service f the prgram. Prper management and administratin f the prgram and as permitted r required by applicable law. I understand: Applicatin t the prgram is entirely vluntary and I may chse t nt cmplete r sign this frm. My decisin will nt change the way my healthcare prviders r health insurers treat me. Hwever, if I d nt cmplete and sign this applicatin, I will nt be able t participate in the Bayer US Patient Assistance Fundatin free drug prgram. Privacy laws may nt prevent further disclsure f my infrmatin after it has been prvided t the prgram, Bayer, their agents, r third-party prviders authrized t administer the prgram. This cnsent t prvide my persnal and medical infrmatin will cntinue until I am n lnger enrlled in the prgram r until I chse t cancel my cnsent, which I may d at any time. I can cancel my authrizatin at any time by writing t the Bayer US Patient Assistance Fundatin, PO Bx 5670, Luisville, KY Cancelling my cnsent will nt have any effect n infrmatin given t r used by the prgram r its agents befre the prgram received my written ntice t cancel the cnsent. I shuld keep a cpy f this frm. I als can get a cpy by cntacting the prgram at BUSPAF ( ). Patient/Representative Signature / / Day Mnth Year Date (required) Check pint! Make sure yu cmpleted every part f the Patient Infrmatin Sectin. A fully cmpleted applicatin is needed t see if yu are eligible fr the prgram. / 5

6 Healthcare Prfessinal Sectin (T be cmpleted by yur healthcare prfessinal) Healthcare Prfessinal (HCP) Name and Cntact Infrmatin HCP name First Last Specialty Address City State Zip cde Phne number Fax DEA # State license # NPI # Office cntact Phne Fax Infrmatin n Patient s Bayer Prescriptin Patient name Date f birth / / First Last Day Mnth Year Bayer prescriptin #1 ICD-10 cde Strength Quantity Number f refills Rx directins Bayer prescriptin #2 ICD-10 cde Strength Quantity Number f refills Rx directins Fr Betasern, it is recmmended t fllw the listed titratin schedule: Weeks 1-2: mg (0.25 cc) QOD SC; Weeks 3-4: mg (0.5 cc) QOD SC; Weeks 5-6: mg (0.75 cc) QOD SC; Weeks 7+: 0.25 mg (1 cc) QOD S Fr Vitrakvi ONLY, has the patient tested psitive fr TRK fusin prteins? Yes N. List r attach ther current medicatins prescribed Knwn drug allergies Yes N List Please check here fr a replacement unit fr: Kyleena, Mirena, r Skyla. Date f Service Required Signature (Dispense as Written): HCP Authrizatin Date (required): / / Day Mnth Year I certify that I am the healthcare prfessinal wh prescribed the medicatin requested in this applicatin fr the sle benefit f the named patient, and that my decisin t prescribe was based n my independent prfessinal judgement. I authrize the Bayer US Patient Assistance Fundatin free drug prgram (the Prgram ), and agents acting n its behalf t use my prvider infrmatin, including Natinal Prvider ID, in the eligibility assessment prcess, and t frward this prescriptin, as necessary, t a dispensing pharmacy. In additin t the abve, my signature belw certifies the fllwing: I will nt charge patients any fee fr r related t their applicatin, enrllment in the Prgram, any c-payment, r ther cst-sharing amunt related t free drug prvided under the Prgram. N claim fr payment fr any prduct prvided thrugh the Prgram may be submitted t any third-party payer, including private insurers, Medicaid r Medicare. This medicatin prvided by the Prgram will nly be utilized by the patient named n this frm, and will nt be ffered fr sale, trade, barter, r returned fr credit. The patient applying fr assistance thrugh the Prgram is being treated in an utpatient setting. T the best f my knwledge, the infrmatin prvided n this frm is current, cmplete and accurate. I understand and acknwledge that (i) submissin f the applicatin des nt guarantee the patient s eligibility in the Prgram; (ii) the Prgram has the right t discntinue the Prgram at any time; and (iii) medicatin prvided thrugh the Prgram fr enrlled patients is nt cntingent n any past, present r future prescriptins fr this r any ther Bayer prduct. Prescriber s Signature (Required): Date (required): / / Please make sure every part f the Healthcare Prfessinal Infrmatin sectin is cmpleted. / 6

7 Checklist If yu are the patient (r caregiver), did yu: Cmplete the Patient Infrmatin Sectin n pages 2-5? Sign and date bth f the Patient Authrizatin Infrmatin sectins n pages 4 & 5? Attach cpies f the prf f incme dcuments selected n page 2 (fr example, yur tax frms) and keep riginal dcuments? Ask yur dctr t cmplete the Healthcare Prfessinal sectin f this frm? Make a cpy f yur cmpleted applicatin fr yur recrds? If yu are the healthcare prfessinal, did yu: Cmplete the HCP Infrmatin Sectin n page 6? Sign and date the Prescriptin sectin? Submit the riginal prescriptin, if required by yur state? Sign and date the HCP Authrizatin? If all the bxes are checked, yu are ready t submit the applicatin. The cmpleted and signed applicatin with financial dcumentatin can be submitted by fax r mail: Fax: If sending the applicatin and dcumentatin by fax, please be sure t include a fax cver sheet. Mail: Bayer US Patient Assistance Fundatin P.O. Bx 5670, Luisville, KY What is the next step after yu send in yur applicatin? We will review and prcess yur applicatin nce we receive the cmpleted frm alng with supprting financial dcumentatin. We will cntact yu nce the review is finished. Questins? If yu have any questins, please call a Bayer US Patient Assistance Fundatin representative at BUSPAF ( ) Mnday thrugh Friday, 8:30 AM t 5:00 PM EST Bayer. All rights reserved. Bayer and the Bayer Crss are registered trademarks f Bayer. PAF-111-US /18 / 7