Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need.

Transcription

1 Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need. Did you know that NeedyMeds has thousands of other free resources? Here s a look at more ways we can help you save money on medicine and healthcare costs. Each one can be found under the Patient Savings tab on our website: Diagnosis-Based Assistance NeedyMeds lists thousands of assistance programs for almost any health condition. If you are going through chemo treatment for cancer, there are programs that can help with wig costs and scalp-cooling products. We also list resources for free diabetes testing supplies, caregiver lodging support, and much more. Free, Low Cost, and Sliding Scale Clinics This popular collection contains information on 16,000+ free, low cost, and sliding scale medical and dental clinics across the U.S. It s a great resource if you need affordable medical treatment and don t know where to go. Coupons, Rebates & More You can use the NeedyMeds website to find nearly 2,000 cost-saving opportunities for both prescription and over-the-counter drugs and medical supplies. Medical Transportation Need help getting to the doctor s office or medical facility? You may be eligible for financial assistance if you meet certain requirements. NeedyMeds also offers information on diagnosis-based camps and retreats, recreational programs, scholarships, government programs, $4 generic drug programs, and more. Finally, I want to tell you about the NeedyMeds Drug Discount Card. Thousands of people use this free, anonymous, and easy-to-use tool to get the best price on their medications. To date, our drug discount card has saved patients over $244,000,000. Check out the next page to learn more. Feel free to call our toll-free helpline if you have any questions. You can reach us at Monday-Friday, 9am-5pm Eastern Time. Thanks for using NeedyMeds! Please let us know if we can do anything else to help you afford the costs of your healthcare. Rich Sagall, MD President, NeedyMeds

2 Clip the card and save NeedyMeds NeedyMeds.org DRUG DISCOUNT CARD BIN: RX PCN: NMEDS RX GRP: PDFPDF ID: NMNA This is a drug discount program, not an insurance plan. NeedyMeds Drug Discount Card Patient: Simply present this card to a participating pharmacy to receive a discount on your prescription. Patients who have Medicare, including Part D, Medicaid or any state or federal prescription insurance can only use this card if they choose not to use their government-sponsored drug plan for their purchase. The card is not valid in combination with those programs. For questions concerning the card, call or visit Pharmacist: Card must be presented to receive program benefits. Clear system of prior cardholder information associated with this universal cardholder ID. For processing questions, call Argus Health Systems at Save up to 80% Use at over 65,000 pharmacies nationwide including all major chains Share the card with friends and family Use the card as often as needed Free, no fees or registration Never expires What if I have insurance? Anyone can use the card, but it can t be combined with insurance. You can use the card instead of insurance if: A drug isn t covered by your insurance Your insurance has no drug coverage You have a high drug deductible You have met a low medicine cap The card offers a better price than your copay You are in the Medicare Part D donut hole What drugs are covered? The card is good for prescription drugs, over-the-counter medicines and medical supplies if written on a prescription blank, and pet prescription medicines purchased at a pharmacy. You ll save on most, but not all, prescriptions. To obtain a plastic drug discount card, send a self-addressed stamped envelope to: NeedyMeds-PAP PO Box 219 Gloucester, MA The card is not valid in combination with other insurance plans, including Medicare, Medicaid or any state or federal prescription insurance. The card can be used only if you decide not to use your government-sponsored drug plan for your purchases.

3 P ATIENT A SSISTANCE P ROGRAM I NSTRUCTIONS Thank you for your interest in the Impax Specialty Pharma Patient Assistance Program. This program is for the ZOMIG (zolmitriptan) family of products, ALBENZA (albendazole), RYTARY (carbidopa and levodopa) extended-release capsules and EMVERM TM (mebendazole) chewable tablets. Attached is a copy of the application form. To be eligible to receive free medicine from Impax Specialty Pharma, patients must be U.S. residents, not have affordable coverage for the prescription, have total household income that meets the program eligibility requirements and, if enrolled in a Medicare Part D plan, have spent at least 3% of annual household income out-of-pocket on prescription medicines. APPLICATION INSTRUCTIONS FOR PATIENTS REQUIRED Fully complete all 3 of below sections: Patient Information (Section 1) Insurance Information (Section 2) Income Information (Section 3) Sign the application Attach a copy of last year s tax return or other records for proof of income. Some examples are IRS Forms 1040, 1040A, 1040EZ, W2, 1099PR, and 1099 Social Security Statement. If you did not file a tax return, please attach an IRS Form 4506-T, which shows that you did not file. If you have a Medicare Part D plan, attach proof of what your household has spent on prescription drugs this year. You will need to provide one of the following: Explanation of Benefits Statement from your Medicare Part D plan provider or a pharmacy printout of year-to-date prescription history. APPLICATION INSTRUCTIONS FOR PRACTITIONERS - REQUIRED Complete Practitioner Information Section 4. Provide phone, fax, and DEA or State License number. Have patient fully complete the Patient Information Sections 2, 3, and 4 and sign the application. Attach original valid prescription(s) with physician signature. Fax or mail the application, financial documentation, proof of prescription spend (if applicable) and prescription to: Impax Specialty Pharma Patient Assistance Program PO Box St. Louis, MO Phone Fax If approved, patients are eligible to receive free medication for up to one year. Medications will be sent to the patient s home. Impax will send an application for renewal when a patient s enrollment is due to expire. For questions regarding this program or application, please call us at , Monday through Friday, 8:00 am to 5:00 pm CST. *If you are a New York or New Jersey Prescriber, please use an original New York State or New Jersey State Prescription Form. ZOMIG 2.5 mg Tablets ZOMIG ZMT 2.5 mg ZOMIG 2.5 mg Nasal Spray ZOMIG 5 mg Tablets ZOMIG ZMT 5 mg ZOMIG 5 mg Nasal Spray RYTARY in the following strengths (available in a 30, 60 or 90 day supply) RYTARY mg / 95 mg RYTARY mg / 145 mg RYTARY mg / 195 mg RYTARY mg / 245 mg ALBENZA 200mg Tablets- 2 count package (available up to a 28 day supply) EMVERM TM 100mg Chewable Tablets-1 count package (Providers please include a separate prescription for every member of the applicant s household being treated with Emverm TM )

4 SECTION 1 - PATIENT INFORMATION: (Please print clearly) Note: Upon approval, medication will be sent to the patient s address Last Name, First Name: Social Security or ID Number: Patient Date of Birth: / / Street Address/Shipping Address: Phone Number: ( ) U.S. Resident: City: State: Zip Code: Marital Status: o Yes Gender: o No List any other Patient Medications: List any Patient Drug Allergies: o Married o Single o Divorced o Widow/Widower o Male o Female U.S. Veteran: Disabled: (Approved by Social Security) Number of people in household (include self): (circle one) Household member also receiving treatment with the Emverm TM Product: 1 st Member: First Name Last Name: DOB: Drug Allergies: 2 nd Member: First Name Last Name: DOB: Drug Allergies: 3 rd Member: First Name Last Name: DOB: Drug Allergies: 4 th Member: First Name Last Name: DOB: Drug Allergies: 5 th Member: First Name Last Name: DOB: Drug Allergies: 6 th Member: First Name Last Name: DOB: Drug Allergies: 7 th Member: First Name Last Name: DOB: Drug Allergies: SECTION 2 - PATIENT INSURANCE INFORMATION Do you have Medicaid? Do you have Medicare A? Do you have a State Patient Assistance Program? Do you have Medicare B? Do you have Medicare D? (If yes, Please attach current years proof of Out-of-Pocket Prescription costs) Do you have prescription drug coverage? (If yes, please attach a copy of your insurance card front and back.) SECTION 3 - PATIENT INCOME INFORMATION Note: Attach Proof of Income (Examples: Federal Tax Return, IRS Form 1040, 1040EZ, 1099, Social Security or Disability Statement)

5 TOTAL GROSS MONTHLY INCOME: $ TOTAL ASSETS*: $ *Only include money in checking or savings accounts, certificates of deposit, stocks and bonds, IRA s, annuities and any other cash holdings. DO NOT include the dollar value of any real estate or personal belongings. If you have recently faced a financial challenge please check the appropriate box below and provide supporting documents with your application. o Change in household income (letter from employer or former employer) o Change in marital status (legal record supporting change) o Change in household number (copy of birth or death certificate) Informed Consent and Authorization for Use and Disclosure of Health Information for Patient Assistance Program I understand that completing this form does not ensure that I will qualify for the Impax Specialty Pharma Patient Assistance Program ( Program ). I represent that the information provided in this qualification form is complete and accurate. I agree to notify and shall be responsible for notifying the Program Administrator for the Program if I obtain coverage through another source or if I no longer meet the income criteria for the Program. I authorize my healthcare provider to disclose medical information and related information to Impax Inc., ( Company ), including Express Scripts Specialty Distribution Services, Inc. any of its subsidiaries or affiliates (the Program Administrator ), and I authorize Company to obtain and disclose information as deemed necessary to verify the accuracy and completeness of this application and to provide services available through the Program. I also authorize Company to release medical information and related information to the Centers for Medicare and Medicaid Services ( CMS ) for purposes of administering the Program. I understand that personal identifying information provided on this form will be available to Company and its agents for the purpose of administering the Program. I understand that Company reserves the right at any time and without notice to me to modify and/or discontinue any or all of the Program, including modification of eligibility criteria and immediate termination of assistance provided by the Program. If I decide to terminate my authorization for my health care providers and my insurers to disclose my information to Company, I shall notify Company in writing at Impax Specialty Pharma Patient Assistance Program, PO BOX St. Louis, MO that I no longer provide such authorization which termination shall be effective upon Company s receipt of such notification. I understand that I have a right to obtain a copy of the information my health care providers or insurers have provided to Company upon request to Company. I understand that I may decline to sign this form and decline being considered for the Program. I understand that signing this form does not affect the way my health care providers or insurer will provide me with their respective services. I understand this authorization is valid for the duration of my enrollment period and the information used or disclosed may be subject to re-disclosure and no longer protected by HIPAA. Original Signature of Patient or Power of Attorney (Required to process application) Date: If signing as POA, please send legal document. X SECTION 4 - PRACTITIONER INFORMATION: (Please print clearly) Please remember to send a separate prescription for the medication being requested. I authorize Impax Inc. to act on my behalf for the limited purposes of transmitting this prescription to the appropriate pharmacy designated by the patient utilizing their benefit plan; provided that if this prescription is not so designated. Impax Inc. is authorized to transmit this prescription to a network pharmacy it selects, or to the pharmacy otherwise indicated. Original Signature of Prescribing Healthcare Provider Required (Must match signature on prescription) X Last Name, First Name: Office Contact Person: Office Street Address: City: State: Zip Code: Phone Number: ( ) State License # (or DEA#, if required): Fax Number: ( ) MAIL/FAX ALL DOCUMENTS TO: Impax Specialty Pharma Patient Assistance Program PO Box St. Louis, MO Phone Fax