NeedyMeds

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1 NeedyMeds Find help with the cost of medicine Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need. REMEMBER - Send your completed application to address on the form, NOT to NeedyMeds. 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. 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 Richard J. Sagall, MD President, NeedyMeds NeedyMeds.org P.O. Box 219 Gloucester, MA Phone: info@needymeds.org

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 Rheumatology Statement of Medical Necessity (SMN) PLEASE DO NOT SEND ANY ADDITIONAL DOCUMENTATION. Phone: (866) Fax: (866) Genentech-Access.com/Rheumatology Required field (*) ACS/062315/0105(1) 10/16 Services requested* (check only those that apply) Benefits Investigation/Prior Authorization Appeals Support Co-pay Assistance GATCF Patient Assistance Step 1: Patient Information Last name*: First name*: DOB*: / / Gender: M F Street: City: State*: ZIP: Home phone: ( ) - Work /cell: ( ) - Patient preferred language (if other than English): OK to contact patient for missing information to perform service(s) requested? Yes No Alternate contact name: Relationship: Alternate phone: ( ) - Step 2: Insurance Information No Insurance Primary insurance name: Phone: ( ) - Subscriber name: Subscriber ID #: Policy/group #: Secondary insurance name: Phone: ( ) - Subscriber name: Subscriber ID #: Policy/group #: Step 3: Treatment/Diagnosis Check one desired patient therapy*: Rituxan (rituximab) ACTEMRA (tocilizumab) IV infusion ACTEMRA SC self-injectable Primary diagnosis code*: Secondary diagnosis code: Prior inadequate response to TNF Has patient started prescribed therapy? Yes No Next date of treatment: / / Concurrent methotrexate prescribed with Rituxan or ACTEMRA Step 4: Prescriber Information Last name*: First name*: Practice name: Specialty: Street*: Suite #: City*: State*: ZIP*: Prescriber tax ID #: Prescriber NPI #: Group NPI #: PTAN : Office contact: Office contact phone: ( ) - Fax: ( ) - Step 5: Infusion and Drug Acquisition Information Specialty pharmacy needed for Rituxan or ACTEMRA dispensing? Yes No (MD s office will supply) Preferred specialty pharmacy: Place of infusion: Prescribing physician s office Other physician s office Hospital outpatient Other: Infusion site name: Infusion site tax ID #: Infusion site NPI #: Street: Suite #: City: State: ZIP: Contact name: Phone: ( ) - Ship to: Patient Prescribing physician's office Infusion site listed above *Required field. Genentech Access to Care Foundation. National Provider Identifier. Provider Transaction Access Number. 1/3

4 Print patient's name here Patient last name*: First name*: DOB*: / / Step 6: Prescription Information For Rituxan (rituximab) Patients Only SIG: Infuse: mg on Day 1 and Day 15 Once a week for 4 weeks Other: Dispense Rituxan vials: 100-mg dose 500-mg dose Refill times For ACTEMRA (tocilizumab) Patients Only Intravenous (IV) infusion SIG: Infuse: mg Once every 2 weeks Once every 4 weeks Other: Dispense ACTEMRA vials: 80-mg dose 200-mg dose 400-mg dose Refill times Subcutaneous self-injectable Inject 162 mg Once a week Once every 2 weeks Other: Dispense: 1 month 2 months 3 months Other: Patient weight: lbs Refill times Step 7: Starter Prescription ACT Fast free starter supply only (ACTEMRA subcutaneous patients only) Drug: ACTEMRA subcutaneous self-injectable 162 mg Dispense: 15-day supply Once every week Once every 2 weeks Patient weight: lbs Refill times Step 8: Sign and Date Form PHYSICIAN CERTIFICATION: By signing below, I certify: (a) the above therapy is medically necessary, (b) I received the authorization to release the information above and other protected health information (as defined by the Health Insurance Portability and Accountability Act of 1996 [HIPAA]) to Genentech, Inc., Genentech Access Solutions, the contracted dispensing pharmacy, or other contractors for the purpose of requesting reimbursement support, assisting in initiating or continuing therapy and/or the evaluation of the patient s eligibility for GATCF, as a break in treatment would negatively impact the patient s therapeutic outcome and (c) I will not attempt to seek reimbursement for free product provided to the patient. I request Genentech Access Solutions convey to the pharmacy chosen by the above-named patient the prescription described herein. I agree to comply with the Genentech, Inc. program guidelines and understand that GATCF, at its sole discretion, reserves the right to modify or discontinue the program at any time and to verify the accuracy of the information submitted. I further understand that Genentech will provide vial replacement in a configuration that will create the least wastage. If applying for GATCF, I certify that (a) this patient has no medical insurance coverage or otherwise meets the financial criteria for the prescribed therapy, and is not eligible for other product financial support programs, and (b) the therapy identified above will not be used in a clinical trial. Note: Prescribers in all states must follow applicable law for a valid prescription and who is considered an authorized prescriber. For prescribers in states with official prescription form requirements, such as New York, please submit prescriptions on an official state prescription blank along with this form. Unapproved Use Warning: Please read the FDA-approved label for Genentech products before prescribing. If the indication for which you are prescribing a Genentech product is not listed in the FDA-approved label, you are prescribing the medication for an unapproved use, meaning that the FDA has not approved the efficacy, dosage amount or safety of this medication when used for such a use. Nevertheless, GATCF will consider providing the medication for your patient with this admonition, based upon your medical order, within program requirements. Sign and date here, then fax to (866) Prescriber s Signature*: Date*: / / (Original signature required. This form cannot be processed without an original signature.) Rituxan and its logo are registered trademarks of Biogen. ACTEMRA and its logo are registered trademarks of Chugai Seiyaku Kabushiki Kaisha Corp., a member of the Roche Group. The Access Solutions logo is a registered trademark of Genentech, Inc Genentech USA, Inc. So. San Francisco, CA All rights reserved. ACS/062315/0105(1) 10/16 Printed in USA 2/3

5 STATEMENT OF MEDICAL NECESSITY (SMN) Please write legibly and complete all required fields (*) to prevent delays. Complete this form online via My Patient Solutions, our online patient management tool. Visit Genentech-Access.com/Rheumatology to register for My Patient Solutions. SERVICES REQUESTED Check the appropriate services requested on behalf of the patient. Genentech Access Solutions and/or GATCF cannot perform services without your specific request TREATMENT/DIAGNOSIS Enter the Diagnosis Code to the highest level of specificity INFUSION AND DRUG ACQUISITION INFORMATION Check the appropriate box to indicate the need for a specialty pharmacy to dispense Rituxan (rituximab) or ACTEMRA (tocilizumab). Genentech Access Solutions will verify with your patient s health insurance plan whether a specialty pharmacy is in network Complete according to the planned (patient has not yet received Rituxan or ACTEMRA) or administered (patient has already been infused with Rituxan or ACTEMRA) dosing Check the appropriate box to indicate the desired infusion location PRESCRIPTION INFORMATION Please indicate the prescribed therapy (Rituxan or ACTEMRA). Complete the dose and refill fields only if you are planning to use a specialty pharmacy to acquire Rituxan or ACTEMRA for your patient, or if you are requesting GATCF assistance for your patient If you will not infuse the patient in your office and need assistance with locating an infusion site, Genentech Access Solutions will verify with your patient s health insurance plan the infusion sites that are in network PRESCRIBER SIGNATURE Requests for appeals support and GATCF patient assistance cannot be processed without an original or stamped signature ATTACH TO COMPLETED SMN Attach a signed and dated Patient Authorization and Notice of Release of Information (PAN) form. Genentech Access Solutions and/or GATCF cannot work with the insurance plan on your patient s behalf without a signed and dated PAN form PROVIDING ADDITIONAL DOCUMENTS OR INFORMATION WITH THIS FORM, OTHER THAN WHAT IS REQUESTED, WILL DELAY PROCESSING. Rituxan and its logo are registered trademarks of Biogen. ACTEMRA and its logo are registered trademarks of Chugai Seiyaku Kabushiki Kaisha Corp., a member of the Roche Group. The Access Solutions logo is a registered trademark of Genentech, Inc Genentech USA, Inc. So. San Francisco, CA All rights reserved. ACS/062315/0105(1) 10/16 Printed in USA 3/3