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 Rubraca Connections A guide for patients Rubraca Connections works with you to help with coverage and treatment support, delivery, and more.

4 Rubraca Connections: Personalized support from day 1 With Rubraca Connections, you and your caregiver get help with*: Starting Rubraca (rucaparib): Identifying your insurance company s preferred specialty pharmacy Working with your doctor s office to ship Rubraca to your home or preferred location at no extra cost (Rubraca is not available at your local drugstore) Affording Rubraca: Understanding your insurance coverage for Rubraca Helping you find programs that may help you pay for Rubraca Continuing Rubraca: Connecting you to 24/7 treatment support from a specialty pharmacy team (advice from your specialty pharmacy team does not replace direction given by your doctor) Supporting you as you adhere to your Rubraca treatment plan, as prescribed by your doctor 2 * You do not need to enroll in Rubraca Connections to get Rubraca. Rubraca cannot be delivered to a PO Box. 24/7 support is only offered by participating specialty pharmacies.

5 Starting Rubraca TM (rucaparib): Get your medicine Have your medicine delivered where and when you need it Rubraca is not available at your local drugstore. Talk to your doctor to find out if you will get your Rubraca treatment from your doctor s office or from a specialty pharmacy (a mail order pharmacy that sells specialty drugs). Rubraca Connections can help you get your medicine shipped directly to you every month from a specialty pharmacy: You can have Rubraca sent to your home or another location* You will get a call from your specialty pharmacy team to talk about delivery and treatment support If you need assistance understanding how to obtain your Rubraca treatment or if you experience delays, contact Rubraca Connections *Rubraca cannot be delivered to a PO Box. 3

6 Affording RubracaTM (rucaparib) Your Access Specialist can help you learn more about financial support programs that may be right for you After you enroll in Rubraca Connections, your Access Specialist will check your coverage and: F igure out your insurance type I f needed, help you find coverage P rovide you with options to help you pay for Rubraca The type of insurance you have can affect the type of payment help for which you may be eligible. There are 3 types of programs that may help you pay for Rubraca (see next page). 4

7 Insurance type Private/commercial insurance You may have this kind of insurance if you are covered through your work or through a healthcare exchange Government insurance (Medicare, Medicaid, and VA/DoD) You may have Medicare if you are 65 years of age or older or disabled You may have Medicaid if you are getting help with insurance from your State Department of Health and Human Services You may get medical benefits from the United States Department of Veterans Affairs (VA), or the Department of Defense (DoD) if you or a family member has served in the United States Armed Forces No insurance, or Rubraca is not covered Payment help Rubraca $0 Co-Pay Program* If you qualify for the Rubraca $0 Co-Pay Program, 100% of your out-of-pocket drug costs are covered, which means you pay $0 for Rubraca. You can receive support of up to $24,000 per calendar year Independent co-pay foundations If you have government insurance, you may be able to get help with out-of-pocket drug costs from an independent co-pay foundation. Your Access Specialist can give you a list of potential foundations Rubraca Connections Patient Assistance Program If you have no health insurance or your health insurance does not cover Rubraca, you may be eligible for this program. Your Access Specialist will let you know if you qualify based on your household income and diagnosis * The program does not cover costs for any other medication, procedure, or diagnostic test. Please see RubracaConnections.com for full Terms and Conditions and eligibility criteria. Available to eligible patients per foundation guidelines. Foundations are third-party independent 501(c)(3) organizations. 5

8 Continuing RubracaTM (rucaparib): 24/7 treatment support from your specialty pharmacy team If you get Rubraca from one of our network specialty pharmacies, you will be connected to a specialty pharmacy team that will*: Answer questions you may have about Rubraca Help you understand the delivery of your Rubraca treatment Work closely with your doctor to track your progress Follow up with you to check on your progress and help you manage any side effects Provide education on topics such as side effects, dose changes, and lifestyle and dietary questions The specialty pharmacy team does not replace the care and advice you get from your doctor or office nurse. To learn more about the specialty pharmacy network, speak to your Rubraca Connections team at or visit RubracaConnections.com 6 * 24/7 support is only offered by participating specialty pharmacies.

9 Helpful tools 7

10 Topics to discuss with your doctor If your doctor prescribes RubracaTM (rucaparib), here are some topics you may want to talk about with him or her to help you understand your treatment: Goal of treatment Length of treatment P ossible side effects ifestyle and dietary questions L Managing work and exercise How to stay healthy during treatment 8

11 Staying organized Use this section to keep your important information in one place My oncologist: Name: Phone: My pharmacy: Name: Phone: My office nurse: Name: Phone: My Rubraca Connections Access Specialist: Name: Phone: My medication: Dose: 9

12 Glossary Co-pay A fixed amount you pay for a covered health service, including prescription drugs Coinsurance The percentage of costs you pay for healthcare Deductible The amount you pay for healthcare before your health insurance starts to cover costs Independent co-pay foundation A non-profit organization that may assist with out-of-pocket medical costs for eligible patients Medicaid A state-run US government health plan for patients who qualify Medicare A US federal program that provides healthcare for people aged 65 years and older 10

13 Out-of-pocket costs Costs for medical care not covered by insurance Private/commercial insurance Coverage you get through your work or by purchasing individually or through a healthcare exchange Specialty pharmacy A mail order pharmacy that sells specialty drugs like Rubraca VA/DoD The United States Department of Veterans Affairs (VA) and the Department of Defense. They offer medical benefits to people who have served in the US Armed Forces 11

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15 Notes 13

16 Enrolling in Rubraca Connections is simple There are 2 ways to enroll in the program: Download the enrollment form from RubracaConnections.com and complete the patient section right on your computer or by hand. Then, fax the form to or mail it to the address listed on the form OR Call Rubraca Connections at Talk to your Access Specialist if you have any questions 14 Copyright 2016 Clovis Oncology. All rights reserved. PP-RUCA-US-0110