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 1-800-503-6897 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 01931 Phone: 978-281-6666 Email: info@needymeds.org
Clip the card and save NeedyMeds NeedyMeds.org DRUG DISCOUNT CARD BIN: 019520 RX PCN: NMEDS RX GRP: PDFPDF ID: NMNA019309901930 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 1-888-602-2978 or visit www.drugdiscountcardinfo.com. 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 1-866-921-7286. 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 01931 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.
CONNECTING PATIENTS TO MEDICATION The Rx Access program helps make it easier for patients who are prescribed Syprine (trientine hydrochloride) or Cuprimine (penicillamine) to have affordable access to the medication they need with: Copay Assistance: Rx Access provides copay assistance through a network of Specialty Pharmacies. Patients who have commercial insurance may be eligible * to receive the prescribed product for as little as $5 Prescription management: Rx Access representatives will connect patients to a specialty pharmacy that will coordinate fulfillment of their prescription Patient Assistance: For patients facing financial challenges in filling their SYPRINE or CUPRIMINE prescription, Valeant Pharmaceuticals has a Patient Assistance Program (PAP). The PAP is subject to eligibility requirements. * To enable Rx Access to determine a patient s eligibility for PAP, the following documentation must be provided: Completed Rx Access enrollment form (with patient and provider signatures) and prescription Documentation of household income (acceptable forms of income documentation include the patient s IRS 1040 form from the most recent tax year, W-2, or Social Security Benefit Statement) Proof of legal US residency (United States, Puerto Rico, or the US Virgin Islands) ENROLLMENT FORM REQUIREMENTS All services offered by Rx Access require a completed enrollment form containing both patient and prescribing healthcare provider signatures. Completed enrollment forms can be mailed or faxed to: Rx Access PO Box 220667, Charlotte, NC 28222-0667 Fax: (855) 735-4624 After reviewing your enrollment form, Rx Access will notify you and your physician by mail of your eligibility determination. If you have any questions about the program or application process, please call (888) 607-7267. Rx Access representatives are available Monday through Friday, 8:00 am 6:00 pm, Eastern Time. Please see Boxed Warning for Cuprimine below regarding the risk of toxicity, and accompanying full Prescribing Information. WARNING FOR CUPRIMINE Physicians planning to use penicillamine should thoroughly familiarize themselves with its toxicity, special dosage considerations, and therapeutic benefits. Penicillamine should never be used casually. Each patient should remain constantly under the close supervision of the physician. Patients should be warned to report promptly any symptoms suggesting toxicity. Please see accompanying full Prescribing Information for Syprine Capsules. * This offer is not valid for any person eligible for reimbursement of prescriptions, in whole or in part, by any federal, state, or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan or any other federal or state health care programs. These patients may qualify for alternative financial assistance. These offers are only good for use with Syprine and Cuprimine. No other purchase necessary. These offers are not health insurance. These offers are not transferable. These offers are not valid with other offers. These offers have no cash value. The patient understands and agrees to comply with the terms and conditions of these offers. Program term eligibility expires December 31, 2018. Valeant Pharmaceuticals reserves the right to rescind, revoke, terminate, or amend these offers at any time, with or without notice. For more information, call a Rx Access representative at 888-607-7267. Syprine and Cuprimine are trademarks of Valeant Pharmaceuticals, International, Inc. or its affiliates.
PRINT THIS PAGE Enrollment Form Page 1 of 2 ATTENTION: THE PATIENT INFORMATION SECTION MUST BE COMPLETED PRIOR TO THE HEALTHCARE PROVIDER FILLING OUT THE PROVIDER CERTIFICATION SECTION Return this completed application with a valid prescription to: Rx Access, PO Box 220667, Charlotte, NC 28222-0667; or by fax: (855) 735-4624 PRESCRIPTION INFORMATION Check the product for which you are requesting assistance: Syprine (trientine hydrochloride) Sig. Cuprimine (penicillamine) Sig. Check the specialty pharmacy you would like to fill your prescription: CVS Specialty AllianceRx Walgreens Prime Accredo Health Group, Inc. US Bioservices Other Specialty Pharmacy PATIENT INFORMATION Patient Name: SS #: DOB: Address: City: State: Zip: Day Phone #: Evening Phone #: Email Address: Yes, I authorize messages to be left on my voicemail regarding the information I ve provided and the status of my prescription. DELIVERY INFORMATION (Please indicate shipping address if different from above) Address: City: State: Zip: Delivery Contact Name: Contact Phone: INSURANCE INFORMATION (Complete or include demographic sheet) Primary Insurance (Include Medicare information, if applicable) Insurance Company Name: Policy ID #: Group #: Phone #: Subscriber Name: Date of Birth: Prescription Card #: Carrier: Rx Card Phone #: Secondary Insurance (Include Medicare information, if applicable) Insurance Company Name: Policy ID #: Group #: Phone #: Subscriber Name: Date of Birth: Prescription Card #: Carrier: Rx Card Phone #: FINANCIAL INFORMATION (Patient assistance only) Current gross annual household income: $ Number of members in household: Income Verification Source: 1040 W-2 Social Security Benefit Statement I, (patient s name), verify that the information provided in this application is complete and accurate. I do not have the financial resources to pay for product. I agree that if I am eligible and receive any free product, approval is not valid for prescriptions reimbursed under Medicaid, a Medicare drug benefit plan, or any other federal or state programs (such as medical assistance programs). Program approval is not valid for Massachusetts residents or where otherwise prohibited by law. The patient is responsible for reporting receipt of this offer to any health insurer, health plan, or third-party payer as may be required. I understand that any assistance in the form of free product is contingent upon my ability to meet the eligibility criteria for the program. I also understand that Valeant reserves the right at any time, and without notice, to modify the application form; modify or discontinue this program and its eligibility criteria; or terminate assistance. PATIENT AUTHORIZATION (Required) I authorize my healthcare providers and health plans to disclose my protected health information ( PHI ) to Valeant and its agents and contractors ( Valeant ) to: (1) establish my eligibility for benefits through Rx Access; (2) communicate with my healthcare providers and me about my medical care; and (3) provide support services including facilitating the provision of product to me. I understand that once my PHI has been disclosed to Valeant, federal privacy laws may no longer restrict its further disclosure. Valeant agrees to use and disclose this information only for the above purposes and as permitted by law. I further understand I may refuse to sign this authorization and that my healthcare providers and health plans may not condition my enrollment in or eligibility for health plan benefits or my treatment on whether I sign this authorization. I agree to immediately notify Rx Access of any change in my insurance status and understand that such changes may render me no longer eligible for assistance through Rx Access. I may cancel this authorization by notifying Valeant in writing and submitting the cancellation by fax or by mail to: (855) 735-4624 or PO Box 220667, Charlotte, NC 28222-0667. This cancellation will not apply to information that has already been disclosed under this authorization before receipt of the cancellation. I am entitled to a copy of this signed authorization, which expires 10 years from the date it is signed by me or as dictated by applicable state law. Patient Signature: Date: Syprine and Cuprimine are trademarks of Valeant Pharmaceuticals, International, Inc. or its affiliates. Any other product/brand names and/or logos are trademarks of the respective owners.
PRINT THIS PAGE Enrollment Form Page 2 of 2 PROVIDER INFORMATION Provider Name: NPI #: DEA #: Tax ID #/Provider ID #: State License #: Site/Facility Name: Street Address: City: State: Zip: Phone #: Fax #: Contact Name: CLINICAL INFORMATION (Please attach valid prescription to form) Diagnosis Code(s): PROVIDER CERTIFICATION (Required) I attest that the information provided is current, and accurate to the best of my knowledge. I certify that product is medically necessary for this patient and I will be supervising the patient s treatments. I have obtained from my patient all required authorizations for the release to Valeant and its agents and representatives of my patient s identification and insurance information. I understand that any information provided is for the sole use of Valeant and its agents and representatives to verify my patient s insurance coverage and to assess, if applicable, patient s eligibility for participation in Rx Access and to otherwise administer Rx Access. I understand that application to Rx Access does not guarantee that assistance will be obtained. I understand that if my patient s insurance status changes, he/she may no longer be eligible for the patient assistance program ( PAP ), and I agree to immediately notify Rx Access if I become aware of such a change in status. I certify that I will not bill for or accept payment from patients (or any third party), in whole or in part, for product obtained through the PAP. I agree that if a retroactive insurer claim decision or policy change results in reimbursement to me for product supplied through the PAP, I will immediately notify a Rx Access representative, and I understand that in such event Valeant will bill me for the reimbursement product, and I agree to be responsible for payment of the bill. I understand that I am under no obligation to prescribe product and that I have not received nor will I receive any benefit from Valeant or its agents or representatives for prescribing product. Check box to confirm your agreement to receiving faxes from Rx Access Provider Signature: Date: Supervising Physician: Date: No stamps. Physician signature required. NY prescriptions must be submitted on NY State Rx form. This offer is not valid for any person eligible for reimbursement of prescriptions, in whole or in part, by any federal, state, or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan or any other federal or state health care programs. These patients may qualify for alternative financial assistance. These offers are only good for use with Syprine and Cuprimine. No other purchase necessary. These offers are not health insurance. These offers are not transferable. These offers are not valid with other offers. These offers have no cash value. The patient understands and agrees to comply with the terms and conditions of these offers. Program term eligibility expires December 31, 2018. Valeant Pharmaceuticals reserves the right to rescind, revoke, terminate, or amend these offers at any time, with or without notice. For more information, call a Rx Access representative at 888-607-7267. Cuprimine and Syprine are trademarks of Valeant Pharmaceuticals International, Inc. or its affiliates. Any other product/brand names and/or logos are trademarks of the respective owners.