FAX completed and signed enrollment form to BMS Access Support at

Transcription

1 Simple Steps t Enrll Physician Cmplete the Services and Treatment sectins n page 1 Cmplete the Physician Infrmatin sectin n page 2 Read, sign, and date Physician Certificatin n page 2 Have the patient fill ut the Financial, Drug & Medicatin Infrmatin sectin n page 3 if requesting Alternative Cverage r Supprt Research r Referral t Bristl-Myers Squibb Patient Assistance Fundatin (BMSPAF) Patient Cmplete the Patient Infrmatin sectin n page 3 If enrllment int the BMS Onclgy C-Pay Assistance Prgram is requested, please read the Prgram Terms and Cnditins n page 4 If requesting Alternative Cverage r Supprt Research r Referral t BMSPAF, cmplete the Financial, Drug & Medicatin Infrmatin sectin n page 3 Read, sign, and date Patient Authrizatin and Agreement (PAA) n page 6 (initial page 5) FAX cmpleted and signed enrllment frm t BMS Access Supprt at What t Expect After Enrllment Physician Yur BMS Access Supprt representative will: Prvide benefit review results within 24 hurs (within ne business day upn receipt f a cmpleted enrllment frm) Prvide additinal assistance ptins that may be available, if requested Please Nte: If referred t BMSPAF, yur ffice will receive a prescriptin frm t cmplete Patient Yur physician s ffice will infrm yu f the results f the benefit review when received If c-pay assistance is requested, yu will receive a letter infrming yu f eligibility if accepted If free prduct is requested frm BMSPAF, yu may need t send yur mst recent federal tax return r ther prf f incme upn request Thank yu fr taking the time t cmplete this enrllment frm. If yu have any questins, please cntact BMS Access Supprt at Bristl-Myers Squibb Cmpany. Access Supprt, the Access Supprt lg, DROXIA, EMPLICITI, LYSODREN, OPDIVO, SPRYCEL, and YERVOY are trademarks f Bristl-Myers Squibb Cmpany. MMUS /17

2 Services t be cmpleted by Physician Services Requested (Please chse all services desired.) M Benefit Review (BR), Prir Authrizatin (PA), Appeals Assistance (AA) M BR, PA, AA Services Perfrmed fr New Enrllment Year Fr a patient currently n ne f the BMS medicines belw. Prvide BR, PA, and AA services as needed, in January. M BMS Onclgy C-Pay Assistance Prgram Prgram nly available fr EMPLICITI, OPDIVO, OPDIVO + YERVOY REGIMEN, and YERVOY. M Screening fr Adjuvant Patient Prgram fr Melanma Cmpleted Access Supprt frm required. Upn review f screening, yu will be asked t cmplete an additinal applicatin (prgram available nly fr YERVOY 10 mg/kg). M Specialty Pharmacy Crdinatin (ral medicatins nly) Preferred Specialty Pharmacy: M Alternative Cverage r Supprt Research (eg, independent charitable fundatin referral) BMS cannt guarantee acceptance by any prgram r fundatin. M Referral t Bristl-Myers Squibb Patient Assistance Fundatin (BMSPAF) BMSPAF is an independent, nn-prfit rganizatin that helps eligible patients get free medicatin. Visit BMSPAF.rg fr eligibility requirements. Treatment t be cmpleted by Physician Medicatin Prescribed M OPDIVO (nivlumab) M DROXIA (hydrxyurea) M EMPLICITI TM (eltuzumab) M LYSODREN (mittane) M OPDIVO (nivlumab) + YERVOY (ipilimumab) REGIMEN M SPRYCEL (dasatinib) M YERVOY (ipilimumab) Treatment Infrmatin Patient Diagnsis: ICD Cde Descriptin Will This Be? M Mntherapy M In Cmbinatin With Therapy Prvided in: M Physician s Office M Hspital M Outpatient Facility M Other: Is Physician in Netwrk with Patient s Insurance? M Yes M N Previus therapy given* Dates Dse (in mg) Frequency Planned therapy* Dates Dse (in mg) Frequency *Include cmbinatin medicatins if relevant. 1 f 6 MMUS /17

3 Physician Infrmatin t be cmpleted by Physician Physician Name First name Last name State License # Physician NPI # Physician Tax ID # State Medicaid # Facility Name Phne Fax Facility Address City State Zip Primary Cntact Name Phne Fax Primary Cntact Address Title Physician Certificatin t be cmpleted by Physician I certify t the fllwing: (1) T the best f my knwledge, the patient and physician infrmatin in this frm is cmplete and accurate; (2) I have the authrity t disclse this patient s infrmatin t BMS, BMSPAF, and their respective agents and assignees, and I have btained this patient s authrizatin fr the disclsure, if required by HIPAA r ther applicable privacy laws; (3) I have prescribed the medicatin t this patient based n my prfessinal judgment f medical necessity; (4) If patient receives medicatin frm BMSPAF, t the best f my knwledge, this patient has n prescriptin insurance cverage (including Medicaid, Medicare, r ther public r private prgrams), r is unable t affrd the cst-sharing requirements assciated with his/her insurance cverage fr this medicatin; (5) I will immediately ntify BMSPAF if my patient is enrlled in BMSPAF and I becme aware that his/her insurance, treatment, r incme status has changed; (6) I will nt submit an insurance claim r ther claim fr payment t anyne else, including third-party payer (private r gvernment) r the patient, and I freg any appeal f any denial f insurance cverage, fr medicatin prvided by either BMS r BMSPAF fr this patient, nr will I cunt the free medicatin twards this patient s true ut-f-pcket csts (TrOOP); (7) Any medicatin prvided by either BMS r BMSPAF fr this patient will be used nly fr this patient and will nt be resld, nr ffered fr sale, trade r barter, r returned fr credit; (8) I will stre BMS r BMSPAF medicatin I receive fr this patient separate frm cmmercially purchased medicatin that is used fr the treatment f ther patients; (9) I will cnfirm each administratin f medicatin and agree t prvide t BMS and BMSPAF prf f administratin, when requested; (10) I will ntify BMS r BMSPAF if any free prduct will nt be administered t this patient and arrange fr BMS r BMSPAF t pick up such prduct. If I d nt permit the return f any free unpened vials prvided and nt used by this patient, I will pay fr them; and (11) I will discard any unused amunts in pened vials. I certify, if the patient enrlls in the BMS Access Supprt Onclgy C-Pay Assistance Prgram, t the fllwing: I have read and will cmply with the Prgram Terms and Cnditins n page 4 T the best f my knwledge, this patient satisfies the Patient Eligibility requirements, and I will ntify the Prgram immediately if the patient s insurance status changes T the best f my knwledge, participatin in this Prgram is nt incnsistent with any cntract r arrangement with any third-party payer t which this ffice/site will submit a bill r claim fr reimbursement fr the cvered BMS medicatin(s) administered t the patient The bill r claim that this ffice/site will submit t the insurer r patient fr payment fr BMS medicatin(s) will have the BMS medicatin(s) listed separately frm any bill r claim fr drug administratin r any ther items r services prvided t the patient I will nt submit an insurance claim r ther claim fr payment t any third-party payer (private r gvernment) fr the amunt f assistance that my patient receives frm the Prgram If this ffice/site receives payment directly frm the Prgram fr this patient, the ffice/site will nt accept payment frm the patient fr the amunt received frm the Prgram I understand that BMS and BMSPAF (1) may verify all infrmatin prvided, and nt allw r suspend participatin if inadequate infrmatin is received; (2) may mdify, limit, r terminate these prgrams, r recall r discntinue medicatins, at any time withut ntice; and (3) are relying n these certificatins. SIGNATURE Date Physician r Licensed Prescriber signature (required n stamps) 2 f 6 MMUS /17

4 Patient Infrmatin t be cmpleted by Patient Persnal Infrmatin Patient name First name Last name M Male M Female Birth date Address City State Zip Hme phne Mbile Insurance Infrmatin D yu have insurance thrugh: M Private/Emplyer-based insurance M VA r military M State assistance prgram fr medicatin M Medicaid (please check all that apply) Medicare M Part A M Part B M Part D M Medicare Advantage M Nne Primary Insurance Carrier Primary insurance plicy # Phne Grup # Plicy hlder Secndary Insurance Carrier Secndary insurance plicy # Phne Grup # Plicy hlder State, Veteran, r Other Prescriptin Cverage Prescriptin Plicy # Phne Grup # Plicy hlder If yu chse Medicaid r Veteran status abve, please chse applicable ptins belw. Medicaid Status M Nt Applied M Denied M Applicatin Pending Veteran Status M Yes M N Applied fr VA M Yes M N Financial, Drug & Medicatin Infrmatin t be cmpleted by Patient (Required if Alternative Cverage r Supprt Research r Referral t BMSPAF is requested) Financial Infrmatin Number f peple in yur husehld (Include yurself, yur spuse, and yur dependents) Yearly husehld incme: $ r Mnthly husehld incme: $ Yur applicatin may be subject t audit r request fr additinal dcumentatin. Scial Security # (ptinal) Drug Allergies D yu have any drug allergies? M Yes M N If yes, please specify: Medicatins What medicatins are yu currently taking? 3 f 6 MMUS /17

5 BMS Access Supprt Onclgy C-Pay Assistance Prgram Terms & Cnditins (prgram nly available fr EMPLICITI, OPDIVO, OPDIVO + YERVOY REGIMEN, & YERVOY) The BMS Onclgy C-Pay Assistance Prgram is designed t assist eligible cmmercially insured patients wh have been prescribed select BMS medicatins with ut-f-pcket deductibles, c-pay, r c-insurance requirements. Patient Eligibility: Yu have cmmercial (private) insurance that cvers yur prescribed Bristl-Myers Squibb (BMS) medicatin, but yur insurance des nt cver the full cst; that is, yu have a c-pay bligatin (ut-f-pcket cst) fr yur prescribed medicatin. Yu are nt participating in any state r federal healthcare prgram including Medicaid, Medicare, Medigap, CHAMPUS, TriCare, Veterans Affairs (VA), r Department f Defense (DD), r any state, patient, r pharmaceutical assistance prgram. Patients wh mve frm cmmercial (private) insurance t a state r federal healthcare prgram will n lnger be eligible. If yu purchased yur prescriptin insurance thrugh a Health Exchange (als knwn as a Health Insurance Marketplace r Small Business Optins Prgram [SHOP] Marketplace), yu are currently eligible. Yu live in the United States r Puert Ric. Prgram Benefits: Yu must pay the first $25 f the c-pay fr each dse f a BMS medicatin cvered by this Prgram. If the patient is administered tw BMS medicatins cvered by this Prgram n the same day, the cmbinatin f thse tw medicatins will be treated as ne dse, requiring the patient pay nly $25 f the medicatins c-pay fr that day. This Prgram will cver the remainder f the c-pay, up t a maximum f $25,000 per BMS medicatin during a calendar year. (Fr clarificatin, if a patient is prescribed tw BMS medicatins in cmbinatin, the maximum is $50,000.) Patients are respnsible fr any csts that exceed the Prgram s per medicatin $25,000 maximum. In rder t receive the Prgram benefits, the patient r prvider must submit an Explanatin f Benefits (EOB) frm, r a Remittance Advice (RA). The submitted frm must include the name f the insurer, plan infrmatin, and shw that the BMS medicatin supprted by this Prgram was the medicatin that was given. The frm must be submitted within 180 days f receiving each dse. The Prgram may apply t retractive ut-f-pcket expenses that ccurred within 120 days prir t the date f the enrllment. These benefits are subject t the $25 patient c-pay requirement and the 12-mnth Prgram maximum f $25,000 per medicatin. The Prgram benefits are limited t the c-pay csts fr BMS medicatins cvered by this Prgram that the patient receives as an utpatient. The Prgram will nt cver, and shall nt be applied tward, the cst f any dsing prcedure, any ther healthcare prvider service r supply charges r ther treatment csts, r any csts assciated with a hspital stay. Prgram Timing: The enrllment perid is 1 calendar year. Patients must enrll by December 31, Additinal Terms and Cnditins f Prgram: Patients, pharmacists, and healthcare prviders must nt seek reimbursement frm health insurance r any third party fr any part f the benefit received by the patient thrugh this Prgram. Patients must nt seek reimbursement frm any health savings, flexible spending, r ther healthcare reimbursement accunts fr the amunt f assistance received frm the Prgram. Acceptance f this ffer cnfirms that this ffer is cnsistent with patient s insurance. Patients, pharmacists, and healthcare prviders must reprt the receipt f c-pay assistance benefits as may be required by patient s insurance prvider. This ffer is nt valid with any ther prgram, discunt, r incentive invlving a BMS medicatin eligible fr this Prgram. Only valid in the United States and Puert Ric; this ffer is vid where prhibited by law, taxed, r restricted. The Prgram benefits are nntransferable. N membership fees. This ffer is nt cnditined n any past, present, r future purchase, including additinal dses. The Prgram is Nt Insurance. Bristl-Myers Squibb reserves the right t rescind, revke, r amend this ffer at any time withut ntice. 4 f 6 MMUS /17

6 Patient Authrizatin and Agreement The BMS Access Supprt prgram is a supprt prgram by Bristl-Myers Squibb Cmpany (BMS) that helps patients understand their insurance cverage and financial supprt ptins fr BMS medicatins, such as c-pay and free medicatin assistance. BMS als screens fr patient assistance frm the Bristl-Myers Squibb Patient Assistance Fundatin, Inc. (the Fundatin), an independent nnprfit that prvides free medicatin t qualifying patients. T participate in the BMS Access Supprt prgram r t apply fr the Fundatin prgram, these prgrams will need t receive, use, and disclse yur persnal infrmatin. Please read this authrizatin fr BMS and the Fundatin carefully, and cntact BMS at if yu have any questins. Once yu have read and agreed t this frm, fax yur signed cpy t What infrmatin will be used and disclsed? My persnal infrmatin will be disclsed, including: Infrmatin n this applicatin frm My cntact infrmatin and date f birth Scial Security number (which is vluntary) Financial and incme infrmatin Insurance benefit infrmatin Health recrds and infrmatin, including medicatins prescribed t me Genetic tests that identify the kind f illness that I have and/r medicatin indicated fr my treatment 2. Wh will disclse, receive, and use the infrmatin? This authrizatin permits my caretakers, which includes my healthcare prviders, pharmacists, health plans, and health insurers wh prvide services t me, as well as ther peple that I say can help me apply, t disclse my persnal infrmatin t BMS, the Fundatin, and their authrized agents and assignees (their Administratrs ). BMS and the Fundatin and their Administratrs may als share my infrmatin with my caretakers and with ther healthcare prviders, pharmacists, health insurers, and charitable rganizatins t determine if I am eligible fr, r enrlled in, anther plan r prgram. 3. What is the purpse fr the use and disclsure? My persnal infrmatin will be used by and shared with the persns and rganizatins described in this authrizatin in rder t: Prcess my applicatin fr bth the BMS Access Supprt and Fundatin prgrams Prvide the BMS Access Supprt prgram services t me, including verifying my insurance benefits, researching insurance cverage ptins, and referring me t ther plans r assistance prgrams that may be able t help me Prvide c-pay assistance t me, if I am eligible Cntact my caretakers and me abut the prgrams and the services that are available Cntact ther healthcare prviders and charitable rganizatins t determine if I am eligible fr, r enrlled in, anther plan r prgram Prvide me with free medicatin thrugh BMS r the Fundatin, if I qualify Imprve r develp the prgrams services 4. When will this authrizatin expire? This authrizatin will be effective fr 5 years unless it expires earlier by law r I cancel it in writing. I may cancel this authrizatin fr either r bth prgrams by writing t: BMS Access Supprt P.O. Bx Charltte, NC If I cancel this authrizatin fr a prgram, I will n lnger be able t participate in that prgram. That prgram will stp using r disclsing my infrmatin fr the purpses listed in this authrizatin, except as necessary t end my participatin r as required r allwed by law. I understand that if I receive free medicatin, I must reapply at least every year, sign an authrizatin fr bth BMS Access Supprt and the Fundatin, and be accepted. (cntinued n next page) Patient r Persnal Representative Initials 5 f 6 MMUS /17

7 Patient Authrizatin and Agreement (cnt d) Onclgy Access and Reimbursement Supprt 5. Ntices I understand that nce my health infrmatin has been disclsed, privacy laws may n lnger restrict its use r disclsure. BMS, the Fundatin, and their Administratrs agree t use and disclse my infrmatin nly fr the purpses described in this authrizatin r as allwed r required by law. I further understand that I may refuse t sign this authrizatin and that if I refuse, my eligibility fr health plan benefits and treatment by my healthcare prviders will nt change, but I will nt have access t the BMS Access Supprt r Fundatin prgrams. I have a right t receive a cpy f this authrizatin after I have signed it. 6. Authrizatin fr a Cnsumer Reprt (fr patients applying r referred t the Fundatin prgram) I authrize the Fundatin and its Administratrs t btain a cnsumer reprt n me. My cnsumer reprt, and infrmatin derived frm public and ther surces, will be used t estimate my incme as part f the prcess t determine if I am eligible t receive free medicatin frm the Fundatin. Upn request, the Fundatin will prvide me the name and address f the cnsumer reprting agency that prvides the cnsumer reprt. I may call the Fundatin at fr this infrmatin. 7. Patient certificatins I certify that the persnal infrmatin that I prvide t BMS and the Fundatin is true and cmplete. I agree that, at any time during my participatin in either r bth prgrams, BMS (and the Fundatin, if applicable) may request additinal dcumentatin t verify my persnal infrmatin. If there is missing infrmatin r I d nt respnd t requests fr additinal dcuments, my participatin may be delayed r I may n lnger be able t participate. If I qualify fr and receive c-pay assistance r free medicatin assistance frm BMS, I agree t cmply with BMS prgram rules and I will nt get reimbursed fr the assistance I receive frm anyne else, including frm an insurance prgram, anther charity, r frm a health savings, flexible spending, r ther health reimbursement accunt. I understand that assistance may be temprary and that I may be required t apply every year. I will cntact BMS Access Supprt at if my insurance r treatment changes in any way. If I qualify fr and receive free medicatin frm the Fundatin prgram, I agree t cmply with the Fundatin s prgram rules; and I will nt get reimbursed fr the assistance I receive frm anyne else, including frm an insurance prgram, anther charity, r frm a health savings, flexible spending, r ther health reimbursement accunt. If I have Medicare Part D, I will als nt cunt any free medicatin I receive twards my true ut-f-pcket csts (TrOOP). I understand that the Fundatin s help is temprary, I must reapply every year, and I may nt be eligible if I have prescriptin drug cverage that will pay fr my medicatin. I agree t immediately cntact the Fundatin at if my insurance, treatment, r financial situatin changes in any way. I understand that the BMS Access Supprt and the Fundatin prgrams may be discntinued r the rules fr participatin may change at any time, withut ntice. I have read this authrizatin and agree t its terms: Print Name f Patient r Persnal Representative Descriptin f Persnal Representative s Authrity Preferred Address Initials Signature f Patient r Persnal Representative Date The patient r his/her persnal representative must be prvided with a cpy f bth pages f this frm after it has been signed. 6 f 6 MMUS /17