PATIENT CARE PROGRAM FAQ & APPLICATION

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PATIENT CARE PROGRAM FAQ & APPLICATION

GenomeDx is committed to ensuring access to all patients eligible for Decipher Through our Patient Care Program, we offer programs designed to ensure testing is affordable for your patients, including: Financial assistance for patients with demonstrated financial need Tailored payment plans to accommodate certain specific financial circumstances. Financial Assistance GenomeDx has a Patient Care Program designed for qualifying patients that are either uninsured, or are insured under commercial insurance plans. Under the program, patients may be eligible for a reduction in their out of pocket copay amount. To be eligible for this program, patients must be appropriate candidates for the Decipher Test (as determined by a physician in their professional judgment), complete a Patient Care Program application, meet specific financial criteria based on certain income guidelines, and be approved for participation by GenomeDx. An application form can be found at the end of this booklet. Payment plans to accommodate specific financial circumstances Separately, for certain eligible Decipher patients, GenomeDx offers customized payment plans to help deal with specific financial circumstances. For more information on the Decipher test and our Patient Care Program, you can contact the GenomeDx Patient Care team at 1-888-792-1601 or visit our website. www.genomedx.com

FREQUENTLY ASKED QUESTIONS Who qualifies for financial assistance? Financial assistance is based on financial need. Eligibility is determined from financial criteria based on a multiple of the United States Department of Health & Human Services (HHS) Poverty Guidelines. These guidelines are subject to change and with it, eligibility in the program. Not every patient who applies for assistance will be qualified. Who isn t eligible for financial assistance? (1) Patients who are eligible to enroll in federally funded assistance (e.g. Medicare or Medicaid) or, patients with secondary insurance that covers out of pocket expenses are not eligible. (2) Financial assistance is not available to patients outside of the 50 United States and the District of Columbia. (3) Where a patient s duly licensed U.S. health care professional has not ordered the Decipher Test for them, the patient is not eligible. Other restrictions may apply. How do I know if I qualify? The GenomeDx Patient Care team is available to qualify patients at any point once the test has been ordered. To find out if you will qualify, contact GenomeDx at 1-888-792-1601. If it is determined that you will qualify, you will be sent an application form. Or you may fill out the Patient Care application form at any time & mail it to: GenomeDx Patient Care 3550 Dunhill St., San Diego, CA 92121 or fax to 1-855- 324-2768. GenomeDx will determine, based on the application and its program rules, whether a patient qualifies, and will notify the patient directly. Will I be contacted by GenomeDx once the test has been ordered by my physician? After the Decipher test has been ordered for you, GenomeDx will contact you to answer any questions you may have about the test and the Patient Care Program. You are encouraged to contact the GenomeDx Patient Care team at any time to find out more about the testing and billing process and whether any Patient Care Programs may be an option for you. Our team is here to answer your questions and provide guidance on what you can expect with regard to the testing, billing and reporting process.

Do I have to apply for the Patient Care Program to receive the Decipher Test? No, but doing so may enable GenomeDx to reduce your cost-sharing amounts. How much will my out of pocket expense be if I qualify for financial assistance? Your copay expense will depend on your income but if you qualify, your copay commitment may be reduced. I received a bill even though I qualified for financial assistance why? All patients will receive a bill, even if you qualify for financial assistance. This is because the normal billing process requires that a bill is sent. If you have qualified for assistance, when you receive a bill, please call GenomeDx directly at 1-888-792-1601 to have your eligibility applied to your bill. I received an Explanation Of Benefits (EOB), what does this mean? When your insurance company processes a claim, you will be sent an EOB notice. An EOB is not a bill, but it may show pending payments or even a claim denial by your insurance company. Sometimes your insurance company denies a claim because they want more information such as medical records, which may be information only your doctor s office can provide. If there are any questions about the procedures or the charges on the EOB, you should contact your insurance company and/or the GenomeDx billing department at 1-888-792-1601 or billing@genomedx.com. Is the Patient Care Program insurance? No. What if I don t qualify for financial assistance? GenomeDx is committed to helping all patients who qualify for Decipher have access to the test. If you don t qualify for financial assistance, payment plans may be available to you. Contact the Patient Care team to discuss alternatives.

What else should I know if I want to apply for GenomeDx patient assistance? As a condition to participating in the GenomeDx Patient Care Program, the patient must report the amount of cost-sharing waived under the Patient Care Program to their insurance company, if required under their insurance contract. GenomeDx may verify the accuracy of the information the patient has provided and may ask for more financial and insurance information. GenomeDx reserves the right to change or cancel the GenomeDx Patient Care Program at any time. Any support provided under the GenomeDx Patient Care Program is not contingent on any future purchase. Patients should not seek reimbursement or credit for the amount of cost-share waived under the Patient Care Program from their insurance provider or payor. Patients should not submit any portion of the amount of cost-share waived under the Patient Care Program to any third party for purposes of counting toward out-of-pocket expenses or accumulators. Patients should have a signed copy of a current and completed HIPAA authorization form on record with their prescriber.

PATIENT CARE APPLICATION FORM GenomeDx Biosciences Patient Care Program is designed for qualifying patients that are either uninsured or are insured under commercial insurance plans. Under the program, you may be eligible for a reduction in your out of pocket copay amount. To be eligible for financial assistance, you must be an appropriate candidate for the Decipher Test and complete and return the information below. A member of the GenomeDx Patient Care Program team will contact you shortly after your application has been received. Please print your information below: NAME: DATE OF BIRTH: ADDRESS: CITY, STATE, ZIP: HOME PHONE: CELL PHONE: EMAIL: PHYSICIAN NAME: NUMBER OF PERSONS IN THE FAMILY HOUSEHOLD: TOTAL GROSS ANNUAL HOUSEHOLD INCOME: Preferred method of contact: Home Phone Cell Phone Email I hereby certify that the information provided by myself or my legal representative is true and accurate. I understand and agree that GenomeDx Biosciences reserves the right at any time and without notice to modify the application form; to modify or terminate the Program and to audit the information I have provided on this form. PATIENT SIGNATURE DATE Please return the completed form to: GenomeDx Patient Care, 3550 Dunhill St., San Diego, CA 92121 Or Fax to: 1-855-324-2768

www.genomedx.com GenomeDx Biosciences Inc 3550 Dunhill St., San Diego, CA 92121 PHONE: 1-888-792-1601 FAX: 1-855-324-2768 Copyright 2014 GenomeDx Biosciences Inc

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