Reimbursement & access Support

Transcription

1 Reimbursement & access Support

2 Cayston Access Program Navigating today s reimbursement environment on behalf of your patients can be challenging. Cayston is distributed through a select group of specialty pharmacies and cannot be obtained through a retail pharmacy. To facilitate access to Cayston, you can complete the following enrollment forms with your patient and have them faxed to the Cayston Access Program at The Cayston Access Program assists with reimbursement and access to Cayston. The Cayston Access Program reimbursement specialists can answer questions related to insurance coverage, financial assistance, specialty pharmacy referral, and claims appeal support. This program may be reached by dialing our toll-free number at CAYSTON ( ). Reimbursement specialists are available Monday Friday from 8 am to 8 pm Eastern Standard Time (EST) to provide you timely and accurate information. The Cayston Access Program can support the following requests from you and your patients: General Information Reimbursement specialists can respond to general questions about Cayston. Insurance Verification Reimbursement specialists can verify patients health insurance benefits, assess their coverage for Cayston, facilitate the prior authorization process, and, if applicable, clarify co-payment obligations. Financial Assistance Reimbursement specialists can refer financially needy patients to a Gilead Solutions for Cayston financial support program and/or research alternative sources of insurance coverage. Specialty Pharmacy Referral Reimbursement specialists can provide contact information for specialty pharmacies stocking Cayston. In addition, providers can send Cayston prescriptions to the Cayston Access Program. Reimbursement specialists will work with the patient s selected specialty pharmacy to ensure product is delivered. Claims Appeal Support Reimbursement specialists can help identify reasons for a denied claim. Specialists can contact the insurer to gather information about the appeal process and provide support throughout the process. In addition, reimbursement specialists can provide sample letters of medical necessity and appeal for Cayston. Cayston is administered using the Altera Nebulizer System, a product of PARI Respiratory Equipment, Inc. The Cayston Access Program also assists with insurance verification, specialty pharmacy referral, and claims appeal support related to the Altera Nebulizer System. 2

3 Gilead Solutions for Cayston Gilead is committed to offering financial support programs to patients in need. Gilead Solutions for Cayston was established to provide financial assistance to insured and uninsured individuals who are experiencing financial difficulty accessing Cayston and, in certain circumstances, the Altera Nebulizer System, provided they meet eligibility criteria. The Cayston Access Program reimbursement specialists can review an individual s unique situation and help determine the best potential financial assistance solution. The Cayston Access Program can be reached by dialing our toll-free number at CAYSTON ( ). The Cayston Patient Assistance Program provides financial assistance to patients who have no third party insurance for Cayston or have third party insurance that has denied coverage for Cayston. Patients who qualify for Cayston assistance may qualify for Altera Nebulizer System assistance for additional or replacement parts of the Altera Nebulizer System. The Cayston Co-Payment Assistance Program is for patients with a commercial insurance co-payment or coinsurance for Cayston above $25. Qualified patients will receive support to supplement their out-of-pocket payment for Cayston. Independent Nonprofit Patient Assistance Foundations There are independent nonprofit patient assistance foundations that provide access to drugs and/or devices for qualifying patients. Uninsured or underinsured patients with government insurance (eg, Medicare or Medicaid) or commercial insurance are typically eligible for foundation support. These patients must meet the eligibility criteria determined by each foundation. Cayston Access Program representatives can investigate financial assistance options and potentially refer individuals to foundations. To learn more about patient assistance foundation support, patients and providers may call CAYSTON ( ). 3

4 Five Steps to Enroll Your Patients for Reimbursement and Access Assistance Obtain the Patient Authorization and the Statement of Medical Necessity Forms Forms may be downloaded from the Internet at You may also call the Cayston Access Program at CAYSTON ( ) for copies of the forms and for assistance in completing the forms. Have your patient or patient s legal guardian complete the Patient Authorization Form Your patient or patient s legal guardian must complete and sign the Patient Authorization Form. Complete the Statement of Medical Necessity Form A member of the healthcare team must complete the Statement of Medical Necessity. The prescribing healthcare professional s signature is required for the form to be considered complete. Make copies of required documents Additional information, such as a photocopy of the front and back of insurance cards, should be provided with all enrollment forms. Submit Patient Authorization, Statement of Medical Necessity, and required documents via fax at Reimbursement specialists at the Cayston Access Program will verify the information provided and process the patient s enrollment into the program. Patient requirements: Complete and sign the Patient Authorization Form Provide a photocopy of the front and back of all insurance cards Healthcare professional requirements: Complete and sign the Statement of Medical Necessity Form Provide a copy of state license 4

5 Cayston Patient Assistance Program Patients may be eligible to participate in the Cayston Patient Assistance Program if no other source for Cayston coverage can be identified. For qualified patients, support is provided in the form of free product. This program may be reached by dialing the Cayston Access Program toll-free number at CAYSTON ( ). Enrollment Process Patients must apply to the program and meet certain qualification criteria. To enroll, the Patient Authorization Form and Statement of Medical Necessity Form must be completed. The healthcare professional must sign the Statement of Medical Necessity Form, and the patient must sign the Patient Authorization Form. Supporting residency, income, and insurance documentation should be submitted with the forms via fax to Forms may be obtained by calling the Cayston Access Program at CAYSTON ( ) or by downloading forms from Eligibility will be communicated after a completed application is received with all supporting residency, income, and insurance documentation. Enrollment Management A patient s case will be reassessed on an ongoing basis by a reimbursement specialist. Every 12 months, if the patient continues to be eligible, a new Statement of Medical Necessity Form and Patient Authorization Form should be submitted via fax to along with updated residency, income, and insurance documentation. 5

6 Cayston Co-pay Assistance Program The Cayston Co-Pay Assistance Program supports patients with commercial insurance who need financial assistance for their Cayston co-payments or coinsurance payments over $25 per 28-day course of Cayston therapy. Patients with Medicare, Medicaid, or similar state or federally funded insurance coverage and residents of Massachusetts are not eligible. Qualified patients will receive a supplement to their out-of-pocket payment for Cayston over $25 per 28-day course of therapy. This program may be reached by dialing the Cayston Access Program toll-free number at CAYSTON ( ). Enrollment Process Patients may apply via telephone at CAYSTON ( ) after they have completed and submitted the Patient Authorization Form. The Patient Authorization Form may be obtained by calling CAYSTON ( ) or by downloading the form from Patients must complete, sign, and fax the Patient Authorization Form to A reimbursement specialist will provide patients with instructions on how to utilize the program benefits immediately after verifying the patient s eligibility through a series of short questions. The Cayston Access Program will automatically screen all Insurance Verification and Specialty Pharmacy Referral service requests received via fax to determine if a patient may be eligible for the Cayston Co-Pay Assistance Program. If a patient is determined to be eligible for the program, the Cayston Access Program reimbursement specialists will provide the patient s selected pharmacy all of the information required for the pharmacy to process the Cayston Co-Pay Assistance Program benefit on behalf of the patient. Program Benefits The Cayston Co-Pay Assistance Program will supplement an eligible patient s Cayston co-payment over $25 per 28-day course of therapy. All specialty pharmacies that supply Cayston accept the benefit. 6

7 While every effort is made to provide helpful information, Gilead makes no representations about the eligibility or guarantees of coverage or reimbursement for any claim or application to the Cayston Access Program. In order to minimize potential reimbursement issues and to learn more about the support programs for which your patients may qualify, we recommend that you contact the Cayston Access Program at CAYSTON ( ) prior to beginning treatment of a patient with Cayston. Contact information: Ph: CAYSTON ( ) Fax: Monday Friday from 8 a m to 8 pm (EST) Cayston Access Program 6931 Arlington Road, 2nd Floor Bethesda, MD Cayston is a registered trademark of Gilead Sciences, Inc. Altera is a registered trademark of PARI Pharma GmbH Gilead Sciences, Inc., Foster City, CA All rights reserved. CP4280