PERSONAL SUPPORT PROGRAM SERVICES AND SUPPORT TO HELP YOU GET STARTED
GETTING STARTED WITH COSENTYX Find out how to get started, what to expect, and how the COSENTYX Connect Personal Support program can help: YOU AND YOUR DOCTOR MUST COMPLETE AND SIGN THE SERVICE REQUEST FORM (SRF) We ll get to work right away investigating your insurance coverage. If you don t have insurance, we ll help you investigate alternative financial assistance programs. SAY HI Your Patient Services Liaison will call you within 1 to 2 business days after a completed and signed (by you and your physician) SRF is submitted to say hello, introduce themselves, and let you know what to expect from the COSENTYX Connect Personal Support Program. GET YOUR STARTER KIT You ll be quickly sent a starter kit to your home. It includes your Patient Services Liaison s contact information, a Medication Guide with answers to questions about COSENTYX, an Instructions for Use brochure with details on how to use your medication, and helpful injection demonstration videos. COSENTYX CONNECT 1
GET IMMEDIATE ACCESS TO MEDICATION IF YOU RE ELIGIBLE QuickStart Program*: If you are an eligible new patient, you ll have immediate access to an initial free trial offer of medication for up to 5 consecutive doses, while awaiting your final insurance coverage determination. Following the QuickStart Program, you may be eligible for one of the two additional offerings below. Continued Free Trial Medication Program*: Immediately after the initial 5 doses included in the QuickStart Program, you may be eligible to receive up to 2 additional doses of free trial medication if you are still awaiting your final insurance coverage determination. * Limitations apply. Please note, participation in the QuickStart and/or the Continued Free Trial Medication Programs is not a guarantee of availability of insurance coverage or alternative fi nancial assistance programs. Programs expire 12/31/15. OR Access Extension Program : Immediately after the initial 5 doses included in the QuickStart Program, if you have commercial insurance that does not cover COSENTYX, you may be eligible to receive additional free medication for up to 6 consecutive doses. If during the Access Extension Program, you are able to obtain insurance coverage approval, you will no longer be eligible for this program. Limitations apply. Please note, participation in the Access Extension Program is not a guarantee of availability of insurance coverage or alternative fi nancial assistance programs. The Access Extension Program offer is not valid under Medicare, Medicaid, or any other federal or state program. This program expires 12/31/15. FIND OUT ABOUT CO-PAY ASSISTANCE You may be eligible for our $0 Co-pay Program if you re commercially insured. Your Patient Services Liaison and support team at the COSENTYX Connect Personal Support Program will help you coordinate this benefit and ensure that it s in place once your medication is available at a specialty pharmacy. Terms & Conditions: Valid only for those with commercial insurance. Offer not valid under Medicare, Medicaid, or any other federal or state program, where product is not covered by patient s commercial insurance, or where plan reimburses you for the entire cost of your prescription drug. Offer is not valid where prohibited by law. Valid only in the US and Puerto Rico. This program is only valid for those patients 18 years and older. This program is not health insurance. Offer may not be combined with any other rebate, coupon, or offer. Novartis reserves the right to rescind, revoke, or amend the program without notice. Patient certifies responsibility for complying with applicable limitations, if any, of any commercial insurance and reporting receipt of program rewards, if necessary, to any commercial insurer. This offer expires on 12/31/15. Patient Instructions: Up to a $16,000 annual cap. If you reach the annual cap of $16,000, you will be responsible for the difference. Offer expires 12/31/15. When you use this offer, you are certifying that you understand the program rules, regulations, and terms and conditions, and that you will disclose and report the use of this offer as may be required by your insurer. You are not eligible if prescriptions are paid by any federal or state program, or where prohibited by law; and you will otherwise comply with the terms and conditions above. GET YOUR SHARPS CONTAINER As part of our free sharps mail-back program, you ll be mailed a recyclable sharps container to easily dispose of your injection materials and return them. Just send your full sharps container back using the pre-paid return label, and you ll be sent a new container. 2 COSENTYX CONNECT COSENTYX CONNECT 3
GET ADDITIONAL INJECTION TRAINING Following the initial training instructions from your healthcare professional, there are additional resources available at no cost to you to support you: LIVE: If your healthcare professional chooses additional in-person injection training for you, your Patient Services Liaison will help to schedule it at a time that s convenient for you ONLINE: Following your initial training, you can also watch a helpful step-by-step injection demonstration video on the USB in the starter kit or at COSENTYX.com Do not try to inject COSENTYX yourself, until you or your caregiver has been shown how to inject COSENTYX by your healthcare provider. ARRANGE FOR HOME DELIVERY If you are receiving free trial medication, you and your healthcare professional may choose to have this initial medication delivered to the doctor s office or to your home. If you choose to have your trial medication delivered to your home, your Patient Services Liaison will help arrange delivery. Once your prescription is available through your health plan at a specialty pharmacy, you may work with your specialty pharmacy to see if home delivery is an option. 4 COSENTYX CONNECT
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