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 GUIDELINES FOR THE FERNDALE LABORATORIES PATIENT ASSISTANCE PROGRAM Patient applications are evaluated on a case-by-case basis by Ferndale Laboratories Inc. ( Ferndale ). In general, participation is limited to individuals who: (1) have an income below the U.S. Poverty Level, adjusted for household size; and (2) lack access to insurance coverage or public programs covering the pertinent medication. Patients approved into the Patient Assistance Program should receive shipment of over the counter product only within 2-3 weeks. They will not receive an acceptance letter. However, patients and /or their physicians will receive a denial letter if an application is denied. If approved, and if medication is over the counter only and doesn t require a doctor s prescription, the medication is sent to the patients home. With the shipment of the product the patient will receive instructions on how to request the next supply of medication. If the medication requires a doctor s prescription, the doctor can write the prescription for up to 6 refills at a time. It is the patient s responsibility to contact our office when you require the next refill. The medication will be sent directly to your Physicians office. After the 6 th refill should the patient still require the medication, re-application is required. Medicines distributed through the Ferndale Laboratories Patient Assistance Program are free of charge to all eligible patients. Ferndale Laboratories is not associated with any individuals or organizations that may charge patients a fee (s) to assist in completing applications for our program. These organizations or individuals are acting independently and do not have Ferndale Laboratories consent. This program offers temporary assistance to patients who meet the following requirements: o The patient has no pharmaceutical insurance coverage. o The patient cannot afford to pay for the medication. o The physician has determined that a Ferndale Laboratories product may be appropriate for treating the patient. o You live in the United States o If the medication requires a doctor s prescription, the doctor must be licensed and practicing medicine in the United States. In reference to the above qualifications you must have exhausted all other insurance options for coverage. Some examples of other insurance coverage include: o Private insurance, HMO s, Medicaid, Medicare, state pharmacy assistance programs, Veterans assistance, or any other social service agency. Note-Patients who meet the above qualifications will generally be eligible for the program. However, Ferndale reserves the right to accept or deny any application or to change or discontinue this program at any time without notice Other Important Information: For Patients: Please discuss the risks and benefits of all medicines with your doctor and take only as prescribed by your doctor. For Healthcare Professionals: Before prescribing any medicine, please read the Prescribing Information. 780 West Eight Mile Road Ferndale, Michigan

4 FERNDALE LABORATORIES, INC. PATIENT ASSISTANCE PROGRAM APPLICATION SECTION 1 THIS SECTION TO BE COMPLETED BY PATIENT OR LEGAL GUARDIAN Patient Name: Address: City: State: Zip Code: Phone: Social Security #: Birth Date: U.S. Resident: YES NO Number of persons (including self) DEPENDENT upon primary income within family Supporting Documentation Required-Must send or fax copy of Social Security/Disability Statement OR W2 OR Income Tax Statement for the year, etc. Non-Reimbursed Medical Expenses Paid out Monthly: Gross Monthly Household Income of Applicant and Dependents. Salary/Wages/Dividends Physician $ Social Security Lab Expenses $ Social Security Hospital $ Supplemental Income Disability Dental $ Unemployment Compensation Vision $ Pension/Annuity Other : Alimony/Child Support Total Month: $ Other: Total Month $ PLEASE PROVIDE INFORMATION REGARDING EACH OF THE FOLLOWING SOURCES OF FUNDING MEDICAL COVERAGE (CIRCLE ONE) PRESCRIPTION DRUG COVERAGE (CIRCLE ONE) Medicare Y N Y N Medicaid Y N Y N Private Insurance Y N Y N Prescription Insurance Y N Y N Employer Insurance Y N Y N HMO/PPO Y N Y N State Medical Aid Y N Y N Veterans Assistance Y N Y N Other: Y N Y N ELIGIBILITY STATUS: (E)- ELIGIBLE, (I)- INELIGIBLE, (P) PENDING DATE APPLIED IF NOT ELIGIBLE, PLEASE PROVIDE EXPLANATION

5 If the Medication you are acquiring is over the counter and doesn t need a doctor s written prescription, please indicate where you would like your medication sent: * OVER THE COUNTER MEDICATIONS ONLY* Patient s Name: Social Security #: C/O: Phone: ( ) Shipping Address: City: State: Zip Code: Date of Birth: PRESCRIPTION INFORMATION TO BE COMPLETED BY THE PHYSICIAN ALL PRESCRIPTION INFORMATION BELOW MUST BE COMPLETED BY PHYSICIAN IN ORDER TO PROCESS PRESCRIPTION. VALID FOR FERNDALE LABORATORIES PRODUCTS ONLY Medication: Date: Directions: Quantity: Refill Times Diagnosis: Physician s Signature Printed Name: MD/DO Address: City: State: Zip Code: DEA#: Phone: ( ) Fax: ( ) Patient s Authorization and Acknowledgement I affirm that the above information is correct and complete to the best of my knowledge. I authorize my physician to provide the above information to Ferndale Laboratories, Inc. ( Ferndale ) and to any third party retained by Ferndale to assist in administering its Patient Assistance Program. I also authorize Ferndale and any third party retained by Ferndale to contact my physician for any additional information required in connection with my application or my participation in the program and I authorize my physician to provide that information. I understand that this is an application only and that Ferndale may decide in its sole judgment whether to grant this application or, if granted, to discontinue my participation in the program at any time. I also understand that my physician, and not Ferndale, is solely responsible for selecting the medication described in this Application. Finally, I understand that Ferndale is not a health care provider and will not provide health care advice. This authorization shall continue in effect as long as I am a participant in the program. I understand that Ferndale will not use or disclose the information contained in this Application without my written permission except: (1) to evaluate my Application; (2) to operate and administer the Patient Assistance Program; (3) when required by law; (4) to your physician; (5) for law enforcement, regulatory and public health purposes; or (6) if all identifying information has been removed. Patient Signature:

6 COMMENTS: PLEASE LIST IN THIS AREA ANY ILLNESSES, MEDICATIONS, (INCLUDING OVER THE COUNTER MEDICATIONS THE PATIENT IS TAKING), AND ANY MEDICAL CONDITIONS, ALLERGIES, ETC.