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 STEP 1 REQUESTED SERVICES Benefits Investigation and Prior Authorization Assistance Other services: Patient Assistance Program STEP 2 PATIENT INFORMATION (REQUIRED) Name (First, MI, Last) Gender Female Male Address City of Birth: (MM/DD/YYYY) State Zip SSN # Phone Best Time to Contact Cell Home Work Morning Afternoon Evening STEP 3 PATIENT INSURANCE INFORMATION (REQUIRED) (Please attach a copy of both sides of the patient's insurance card(s). If not available, please complete the information below) Patient drug coverage? Yes No Insurance Type HMO PPO Medicaid Medicare Primary Insurance Name Beneficiary/Cardholder Name Policy ID # Group # Primary Insurance Phone Secondary Insurance Name (if applicable) Beneficiary/Cardholder Name Policy ID # Group # Primary Insurance Phone If patient has a separate prescription coverage plan, please list below. (Medicare patients please use Medicare Part D information) Pharmacy Benefit Plan Name (if applicable) Policyholder Name Policy ID # Rx Group # Rx BIN Rx PCN PBM Phone Secondary Benefit Plan Name (if applicable) Policyholder Name Policy ID # Rx Group # Rx BIN Rx PCN PBM Phone STEP 4 PATIENT FINANCIAL INFORMATION (REQUIRED FOR ALTERNATE FUNDING ONLY) U.S. Resident: Yes No Total Number of People Living in the Household Including Patient: Disabled: Yes No Total Number of People Contributing to Household Income: Total Monthly Income Including All People Contributing to the Income $ IMPORTANT: Do you have a copy of last year's federal income tax return? Yes No If you marked Yes, you must include a copy of last year's federal income tax return for yourself, your spouse and dependents. If your income has changed significantly, or if you are no longer employed, send a new income statement or proof of unemployment. If you marked No, you must include a copy of: IRS Form 4506T SSA-1099 All income statement from jobs held last year

4 STEP 5 HEALTHCARE PROVIDER INFORMATION (REQUIRED) Healthcare Provider Name (First, MI, Last) Practice Name Specialty Address City State Zip NPI # DEA # State License # Tax ID # Phone # Fax # Practice Contact First and Last Name Contact Phone # Contact Address STEP 6 PREFERRED PRODUCT ACQUISITION Specialty Pharmacy Preferred Specialty Pharmacy (used if specialty pharmacy is not payer mandated) Fax # Phone # STEP 7 PRESCRIPTION INFORMATION AND PROVIDER AUTHORIZATION ICD-10 Diagnosis Code Prescribed Dose Odomzo (sonidegib) 200 mg Please attach your prescription if this form does not comply with your state laws. Dosing Instruction Take Tablet(s) Time(s) per Day Quantity # Day Supply Refill Void After Days Primary Diagnosis/ICD-10 Secondary Diagnosis/ICD-10 Sun Pharma Inc and its contractors and agents (together Sun Pharma ), will use the information you provide to administer and improve the ODOMZO SUN Patient Access Program (the Program ). By Signing below, I (the prescriber) understand and agree that: I have prescribed ODOMZO (sonidegib) based on my professional judgement of medical necessity Any medication supplied by Sun Pharma as a result of this form are for use of the named patient only and shall not be sold, traded, bartered, transferred, returned for credit, or submitted to any third-party payer (private or government) for reimbursement Sun Pharma may modify or terminate the program at any time without notice My patient has provided a signed HIPAA Authorization that allows me to share protected health information with Sun Pharma for purposes of this program Prescriber Signature Patient Assistance Program (PAP) Consent for Physician (Mandatory for Patients Enrolling in the Patient Assistance Program)

5 STEP 8 PATIENT AUTHORIZATION AND CONSENT (REQUIRED) By signing below I give permission for my health care providers (HCP), my pharmacies, my health insurer(s), and third-party contractors or service providers to disclose my personal information, including information about my insurance, prescriptions, medical condition and health ( Personal Information ) to Sun Pharma Inc., its affiliates, business partners, service providers, third-party contractors, and agents (together, Sun Pharma ) so that Sun Pharma can (i) help to verify or coordinate insurance coverage or otherwise obtain payment for my treatment with the Sun Pharma Oncology medication prescribed by HCP on the Service Request Form, (ii) coordinate my receipt of, and payment for the Sun Pharma Oncology medication prescribed by HCP on this Service Request Form, (iii) facilitate my access to the Sun Pharma Oncology medication prescribed by HCP on this Service Request Form, (iv) provide me with information about the Sun Pharma Oncology medication prescribed by HCP on this Service Request Form, disease awareness and management programs and educational materials, (v) manage the patient access program, (vi) provide me with adherence reminders and support, and (vii) conduct quality assurance, surveys, and other internal business activities in connection with the patient support program. I give permission to Sun Pharma to disclose my Personal Information to any pharmacies, my health insurer(s), health care providers, my caregivers, and other third parties for the purposes described above. I give permission to Sun Pharma to contact me directly for the purposes described above. I understand that my pharmacy, health insurer(s), and health care providers may receive remuneration (payment) from Sun Pharma Inc. in exchange for disclosing my Personal Information to Sun Pharma Inc and/or for providing me with therapy support services. I understand that once my Personal Information is disclosed it may no longer be protected by federal privacy law. I understand that I may refuse to sign this authorization. I also may revoke (withdraw) this authorization at any time in the future by calling ODOMZO ( ). My refusal or future revocation will not affect the commencement or continuation of my treatment by my doctor(s); however, if I revoke this authorization, I may no longer be eligible to participate in the patient access program. If I revoke this authorization, Sun Pharma will stop using or sharing my information (except as necessary to end my participation in the program) but my revocation will not affect uses and disclosers of my Personal Information previously disclosed in reliance upon this authorization. I understand that this authorization will remain valid for five (5) years after the date of my signature, unless I revoke it earlier. I also understand that the patient access program may change or end at any time without prior notification. I understand that I have the right to receive a copy of this form. I agree to be contacted by Sun Pharma by mail, , telephone calls, and text messages at the number(s) and address(es) provided on the Service Request Form for all purposes described in this Patient Authorization. I confirm that I am the subscriber for the telephone number(s) provided and the authorized user for the address(es) provided, and I agree to notify Sun Pharma promptly if any of my number(s) or address(es) change in the future. I understand that my wireless service provider s message and data rates may apply. I understand that Sun Pharma Inc does not permit my Personal Information to be used by its business partners for their own separate marketing purposes. I understand and agree that Personal Information transmitted by and cell phone cannot be secured against unauthorized access. I also consent to receive marketing information, offers, and promotions from Sun Pharma regarding my disease and related conditions and other products and therapies available from Sun Pharma (the "Marketing Program") and to be contacted for my opinions regarding them. I understand that the Personal Information I supply to Sun Pharma Inc. will be shared with and among its business partners to bring me the Marketing Program and/or to conduct market research. I may opt-out of the Marketing Program by separately checking the Opt-Out Box below or by calling ODOMZO ( ). Patient Signature Parent / Legal Guardian Signature (*Required if patient is a minor) By signing below, I grant permission for the ODOMZO SUN Patient Access Program to contact the Authorized Patient Representative listed to discuss any information provided within this enrollment or consent form, to discuss my treatment with ODOMZO, and to make decisions on my behalf related to my ongoing needs from ODOMZO SUN Patient Access Program. I understand that Sun Pharma is not liable for any actions taken in response to direction provided by my Authorized Patient Representative. Authorized Patient Representative Name Phone Parent / Legal Guardian Signature Opt_out Box for Marketing Please do not send me marketing information, offers, and promotions from Sun Pharma as described under "Marketing Program" in the Patient Authorization section. I understand that I will be contacted by Sun Pharma in connection with the patient access program as described in the Patient Authorization.