XEOMIN (incobotulinumtoxina) PATIENT SAVINGS PROGRAM

Transcription

1 XEOMIN (incobotulinumtoxina) PATIENT SAVINGS PROGRAM For patients who qualify, Merz will reimburse eligible actual out-of-pocket XEOMIN medication costs and related administration fees Eligible patients can receive up to $3,500 EVERY 12 MONTHS Get help with actual out-of-pocket costs associated with XEOMIN treatment, including: Deductibles Co-pays Co-insurance Jan* Ruben* for better patient experiences *Actual patients. Please see page 10 for patient indications. Please see inside for Important Consumer Safety Information. For full Prescribing Information and Medication Guide, please visit Subject to eligibility. Restrictions apply to eligibility and reimbursable expenses. Please see full terms and conditions in this brochure and at XEOMIN.com. Merz reserves the right to change Program Terms and Conditions, including the eligibility requirements, at any time. 1

2 XEOMIN Savings in 3 Easy Steps The XEOMIN Patient Savings Program supports eligible patients with co-pays, co-insurance, and deductibles for XEOMIN and related administration costs, up to a maximum amount of $3,500 per rolling 12-month period. The initial 12-month period begins with a patient s acceptance into the Program. Start saving on out-of-pocket costs with the XEOMIN Patient Savings Program in 3 easy steps: Please refer to the Frequently Asked Questions on page 6 for more information on the XEOMIN Patient Savings Program and how your healthcare provider can support you with the process. Ruben* STEP ONE Enroll in the Program STEP TWO Receive Your XEOMIN Treatment STEP THREE Obtain Your Program Savings Obtain an application. Decide where you want your Program savings to go: directly to you or on your behalf to your healthcare provider (ask your doctor for more information on this option). Sign and submit your enrollment form to the Program (for your convenience, you can ask your healthcare provider to submit it for you). After receiving your XEOMIN injection, your healthcare provider will submit a claim to your insurance company. If approved by your insurance, you and your healthcare provider will receive a statement, called an Explanation of Benefits (EOB), outlining the costs you owe your healthcare provider for your injection. Submit your EOB to the Program (or you can ask your healthcare provider to submit it on your behalf). Depending on where you decided to have your Program savings sent, either you (or your healthcare provider on your behalf) will receive a check with your eligible savings (up to $3,500 per 12 months). You may be required to pay upfront for your co-pay/co-insurance, as determined by your insurance coverage/ policy and your healthcare provider s co-pay collection practice. 2 *Actual patient. Please see page 10 for patient indications. Please see inside for Important Consumer Safety 3 Information. For full Prescribing Information and Medication Guide, please visit

3 XEOMIN Patient Savings Program Example See how Mary s example can save her up to $3,500/year. Not actual patient Meet Mary, 56 (For example only, not an actual patient) Diagnosis: Upper Limb Spasticity After my stroke, I was blessed to work with my care team to help me regain mobility and function of my left arm. But I noticed my arm becoming stiff and painful. And my hand started to stay clenched in a fist. I was diagnosed with Upper Limb Spasticity, and my doctor felt XEOMIN may be right for me. I have a commercial insurance plan that covers my XEOMIN treatment, but still have out-of-pocket costs things like co-pays, co-insurance, and deductibles related to my treatment. XEOMIN Treatment 1 (patient has not yet met her deductible) Patient Costs (Without Program Savings)gs) Patient Costs (With Program Savings) $1,732 $0 XEOMIN Treatment 2 $532 $0 XEOMIN Treatment 3 $532 $0 XEOMIN Treatment 4 $532 $0 Total out-of-pocket costs 0 $3,328 $ It was easy to enroll in the XEOMIN Patient Savings Program. I filled out a form and was notified that I qualified for the program. I found out I may be eligible to receive up to $3,500 every 12 months to apply towards those out-of-pocket costs. By enrolling in, and being deemed eligible for the XEOMIN Patient Savings Program, Mary pays $0 for the above XEOMIN treatment. The XEOMIN Patient Savings Program is an example of how Merz can help patients receive the treatment they need. Enroll in the XEOMIN Patient Savings Program today. Ask your doctor for more information. Take a look at the example patient savings on the chart on the right: Please note Mary s story is an example calculation for illustrative purposes only and assumes hypothetical pricing for a patient receiving 400 units of XEOMIN in the hospital outpatient setting with a deductible of $1,500, a 20% co-insurance, and an out-of-pocket maximum of $3,500. XEOMIN pricing is subject to change. Your benefits may vary depending on your specific commercial insurance plan. 4 Please see inside for Important Consumer Safety Information. For full Prescribing Information and Medication 5

4 Frequently Asked Questions What is the maximum amount of reimbursement I may receive? The maximum reimbursement you may receive for actual out-of-pocket XEOMIN medication costs and eligible administration fees is $3,500 in a 12-month period (beginning on the date you are accepted into the XEOMIN Patient Savings Program). Once I submit my enrollment form, how long will it take to find out if I am eligible for the Program? Will I receive confirmation of my eligibility? Your eligibility will be determined within 2-3 business days of receiving your application. You will then be mailed a welcome letter. Will I be required to re-enroll in the Program after 12 months? You must re-enroll to have your eligibility re-evaluated on an annual basis (every 12 months). How can my healthcare provider support me in the Program? You can ask your healthcare provider s office to support you with the XEOMIN Patient Savings Program in the following ways: 1. They can submit your application to the Program on your behalf. 2. Within 120 days of your injection, they can submit documentation (ie, an Explanation of Benefits) to the Program to initiate your request for reimbursement from the XEOMIN Patient Savings Program. What if I get my XEOMIN through a specialty pharmacy? Am I still eligible for the Program? Some patients may be eligible for coverage of XEOMIN through a specialty pharmacy benefit. In this case, your XEOMIN will be shipped directly to your healthcare provider s office, but will require your participation in the process. You are still eligible to participate in the XEOMIN Patient Savings Program and should talk to your healthcare provider for more information. Enrollment Is Easy: To enroll in the XEOMIN Patient Savings Program, complete application, available by: Visiting and clicking on the Patient Savings Program link Speaking to your healthcare provider Calling MYMERZ ( ) to reach a NEXT STEPS specialist Fax your application to (or, for your convenience, your healthcare provider can submit it for you). Ask questions about financial assistance, call a dedicated nurse, or learn more about patient education resources at MYMERZ ( ) and ask for a NEXT STEPS specialist. You can also always visit us at What is assignment of savings? For your convenience and peace of mind, you can choose to assign (send) your savings directly to your healthcare provider to cover the costs you would have had to pay your provider for your XEOMIN treatment. For additional information or questions on assignment of savings, please contact your healthcare provider s office. Jan* Ruben* Dona* 6 *Actual patients. Please see page 10 for patient indications. Please see inside for Important Consumer Safety 7 Information. For full Prescribing Information and Medication Guide, please visit

5 To be eligible for the XEOMIN Patient Savings Program, you must: Be a clinically appropriate patient for therapeutic treatment with XEOMIN, as determined by your doctor Be prescribed XEOMIN Be at least 18 years of age and less than 65 years of age Have commercial insurance that covers XEOMIN medication costs Not be enrolled in a state-funded or federally funded prescription insurance program* For residents of Massachusetts, Michigan, Minnesota, and Rhode Island, further restrictions apply* Submit claims within 120 days of date of service The following costs are not eligible and will not be reimbursed: Office visit co-pays not directly associated with XEOMIN treatment Facility co-pays not directly associated with XEOMIN treatment Any other costs excluded by the Program guidelines not specifically mentioned above, which are subject to change In accordance with state law, the Program does not reimburse injection-related charges for patients residing in Massachusetts, Michigan, Minnesota, and Rhode Island *Please refer to the complete description of Eligibility, Terms and Conditions, and Program Limitations. Eligibility, Terms and Conditions, and Program Limitations From and after July 1, 2016, the Program covers eligible patients actual out-of-pocket XEOMIN medication costs and related administration fees up to a maximum amount of $3,500 per 12-month period beginning with the patient s acceptance into the Program (no earlier than July 1, 2016). The Program does not cover (a) office visit co-pays not directly associated with XEOMIN treatment; (b) facility co-pays not directly associated with XEOMIN treatment; or (c) any other costs excluded by the Program guidelines not specifically mentioned herein, which are subject to change. Prior Program benefits and limitations apply up to and through June 30, Eligible patients must be clinically appropriate patients for therapeutic treatment with XEOMIN. Patients must be prescribed XEOMIN. Eligible patients must be at least 18 years of age and less than 65 years of age. This offer is valid only in the United States, excluding where it is otherwise prohibited by law. Patients residing in the states of Massachusetts, Michigan, Minnesota, and Rhode Island are eligible for drug co-payment assistance only and are not eligible for other types of co-payment assistance, including but not limited to costs related to administration of the drug. Eligible patients must have private commercial insurance that covers medication costs for XEOMIN, and acceptance of this offer must be consistent with the terms of that insurer s drug benefit. Eligible patients must not have coverage for XEOMIN through Medicare, Medicare Advantage, Medicare Part D, Medicare Part B, Medicaid, Medigap, TRICARE, Veterans Affairs (VA), the Department of Defense (DOD), or other federally funded or state-funded healthcare programs. Patients who move from commercial to federally funded or state-funded insurance will no longer be eligible for the Program. Proof required for receiving payment for out-of-pocket drug costs must be a valid Explanation of Benefits (EOB) or specialty pharmacy invoice, which must be submitted within 120 days after each treatment. Patients may not seek reimbursement for value received from the Program from any third-party payers, including flexible spending accounts or healthcare savings accounts. If at any time, a patient begins receiving coverage under any federal, state, or government-funded healthcare program, the patient is no longer eligible to participate in the Program and must call XEOMIN ( ) between 8 AM and 8 PM (ET) to stop participation. Restrictions may apply. This is not health insurance. 8 Please see inside for Important Consumer Safety Information. For full Prescribing Information and Medication 9

6 Eligibility, Terms and Conditions, and Program Limitations (Continued) Patient and patient s pharmacist are responsible for notifying insurance carriers or any other third party that pays for or reimburses any part of the prescription filled using the Program, as may be required by the insurance carrier s terms and conditions and applicable law. Enrollment in the Program may be reviewed on an annual basis to determine continued eligibility. This offer may not be combined with any other coupon, discount, prescription savings card, free trial, or other offer for XEOMIN. This is a limited time offer, and Merz reserves the right to rescind, revoke, amend, or terminate this offer, or the program in its entirety, at any time, without notice. XEOMIN IMPORTANT CONSUMER SAFETY INFORMATION Read the Medication Guide before you start receiving XEOMIN (Zeo-min) and each time XEOMIN is given to you as there may be new information. The risk information provided here is not comprehensive. To learn more: Talk to your health care provider or pharmacist Visit to obtain the FDA-approved product labeling Call XEOMIN Jan, cervical dystonia patient Ruben, upper limb spasticity patient Dona, blepharospasm patient Uses XEOMIN is a prescription medicine that is injected into muscles and used to treat: increased muscle stiffness in the arm of adults with upper limb spasticity abnormal head position and neck pain in adults with cervical dystonia (CD) abnormal spasm of the eyelids (blepharospasm) in adults who have had prior treatment with onabotulinumtoxina (BOTOX ) It is not known whether XEOMIN is safe or effective in children. Warnings XEOMIN may cause serious side effects that can be life threatening. Call your doctor or get medical help right away if you have any of these problems anytime (hours to week) after treatment with XEOMIN : Problems with swallowing, speaking, or breathing can happen within hours to weeks after an injection of XEOMIN if the muscles that you use to breathe and swallow become weak. Death can happen as a complication if you have severe problems with swallowing or breathing after treatment with XEOMIN. People with certain breathing problems may need to use muscles in their neck to help them breathe and may be at greater risk for serious breathing problems with XEOMIN. Swallowing problems may last for several months, and during that time you may need a feeding tube to receive food and water. If swallowing problems are severe, food or liquids may go into your lungs. People who already have swallowing or breathing problems before receiving XEOMIN have the highest risk of getting these problems. Spread of toxin effects. In some cases, the effect of botulinum toxin may affect areas of the body away from the injection site and cause symptoms of a serious condition called botulism. The symptoms of botulism include: loss of strength and muscle weakness all over the body, double vision, blurred vision and drooping eyelids, hoarseness or change or loss of voice, trouble saying words clearly, loss of bladder control, trouble breathing, trouble swallowing. 10 Please see inside for Important Consumer Safety Information. For full Prescribing Information and Medication 11

7 These problems could make it unsafe for you to drive a car or do other dangerous activities. Do not take XEOMIN if you: are allergic to XEOMIN or any of the ingredients in XEOMIN (see the end of this Guide for a list of ingredients in XEOMIN ), had an allergic reaction to any other botulinum toxin product such as rimabotulinumtoxinb (MYOBLOC ), onabotulinumtoxina (BOTOX, BOTOX COSMETIC), or abobotulinumtoxina (DYSPORT ) or have a skin infection at the planned injection site. Ask a doctor before use if you have a disease that affects your muscles and nerves (such as amyotrophic lateral sclerosis [ALS or Lou Gehrig s disease], myasthenia gravis or Lambert-Eaton syndrome) have had any side effect from any other botulinum toxin in the past have a breathing problem such as asthma or emphysema have a history of swallowing problems or inhaling food or fluid into your lungs (aspiration) have bleeding problems have drooping eyelids have plans to have surgery have had surgery on your face are pregnant or plan to become pregnant. It is not known if XEOMIN can harm your unborn baby. are breastfeeding or plan to breastfeed. It is not known if XEOMIN passes into breast milk. Tell your doctor about all of your medical conditions and all of the medicines you take, including prescription and over-the-counter medicines, vitamins and herbal supplements. Using XEOMIN with certain other medicines may cause serious side effects. Do not start any new medicines until you have told your doctor that you have received XEOMIN in the past. Especially tell your doctor if you have received any other botulinum toxin product in the last four months have received injections of botulinum toxin such as rimabotulinumtoxinb (MYOBLOC ), onabotulinumtoxina (BOTOX, BOTOX COSMETIC) and abobotulinumtoxina (DYSPORT ) in the past. Be sure your doctor knows exactly which product you received. The dose of XEOMIN may be different from other botulinum toxin products that you have received. have recently received an antibiotic by injection take muscle relaxants take an allergy or cold medicine take a sleep medicine take a blood thinner medicine Ask your doctor if you are not sure if your medicine is one that is listed above. Possible Side Effects XEOMIN can cause serious side effects that can be life threatening. See Warnings. The most common side effects of XEOMIN include: dry mouth discomfort or pain at the injection site tiredness headache neck pain muscle weakness eye problems, including double vision, blurred vision, drooping eyelids, swelling of your eyelids, and dry eyes. Reduced blinking can also occur. Tell your doctor or get medical help right away if you have eye pain or irritation following treatment. XEOMIN may cause other serious side effects including allergic reactions. Symptoms of an allergic reaction to XEOMIN may include: itching, rash, redness, swelling, wheezing, asthma symptoms, dizziness or feeling faint. Tell your doctor or get medical help right away if you have wheezing or asthma symptoms, or if you get dizzy or faint. 12 Please see inside for Important Consumer Safety Information. For full Prescribing Information and Medication 13

8 These are not all the possible side effects of XEOMIN. Call your doctor for medical advice about side effects. You may report side effects to FDA at FDA Directions XEOMIN is a shot (injection) that your doctor will give you. XEOMIN is injected into your affected muscles. Your doctor may change your dose of XEOMIN until you and your doctor find the best dose for you. General information about the safe and effective use of XEOMIN Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use XEOMIN for a condition for which it was not prescribed. Do not give XEOMIN to other people, even if they have the same symptoms that you have. It may harm them. You can ask your pharmacist or doctor for information about XEOMIN that is written for health professionals. Active Ingredient: incobotulinumtoxina Inactive Ingredients: human albumin and sucrose Access to XEOMIN treatment is our goal with over 1 Million patients worldwide treated with XEOMIN. To learn more about XEOMIN and how Merz can help, visit 14 Please see inside for Important Consumer Safety Information. For full Prescribing Information and Medication 15

9 Copyright 2016 Merz North America, Inc. All rights reserved. Merz, the Merz logo, and XEOMIN are registered trademarks of Merz Pharma GmbH & Co. KGaA. Botox, Dysport, and Myobloc are registered trademarks of their respective owners. EM Please see inside for Important Consumer Safety Information. For full Prescribing Information and Medication