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 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 President, NeedyMeds
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 www.needymeds.org 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.
SERVICE REQUEST FM (SRF) AND PRESCRIPTIONS All fields required, unless noted. PHONE: 1-844-267-3689 FAX: 1-844-666-1366 Include copy of the insurance card(s) (front and back) and complete all the information below. New York prescribers please note: The COSENTYX Connect Personal Support Program or the Network Specialty Pharmacy will contact you to submit your erx as they are needed. 1. PATIENT INFMATION (Section 1 to be completed and signed by patient) Patient s Name (First, MI, Last) Cell Phone Home Phone DOB (MM/DD/YYYY) Sex: M F Street Address City State Zip Code E-mail (optional) I have read and agree to the Terms and Conditions for participation in the COSENTYX Co-pay Assistance Program on page 3. PATIENT/LEGAL GUARDIAN SIGNATURE I have read and agree to the Patient Authorization on pages 2 and 3. 2. INSURANCE INFMATION (Section 2 to be completed by patient) OK to leave message about COSENTYX on: Cell Phone Home Phone Preferred Language: English Spanish Other Alternate Contact Name Relationship to Patient If eligible, I would like to be connected with the Patient Assistance Program (PAP) application process. (optional) Beneficiary/Cardholder Name Primary Insurance Phone # Primary Insurance ID # Group # Prescription Insurance ID # Rx Group # Rx BIN # Rx PCN # Secondary Insurance ID # Group # F HEALTHCARE PROVIDER USE ONLY 3. PRESCRIBER INFMATION (Sections 3 7 to be completed by the prescriber) Prescriber s Name (First, Last) Office Phone Office Fax Office Contact Name Office E-mail (optional) Tax ID # NPI # Site Institution Name (optional) Address City State Zip Code 4. CLINICAL INFMATION PRIMARY DIAGNOSIS/ICD-10 Codes: (check all that apply) L40.00: (Plaque psoriasis) L40.50: (Arthropathic psoriasis, unspecified) L40.59: (Other psoriatic arthropathy) M45.0: (Ankylosing spondylitis) Other ICD-10 Code(s): Has patient participated in a COSENTYX clinical trial? YES NO The patient has previously been treated with a biologic for the diagnosed condition. YES NO If patient has been treated with a biologic, please answer the following questions. Does this patient have a contraindication, intolerance, or allergy to Enbrel, Humira, Remicade, Stelara, Cimzia, Simponi, Taltz, or other biologic treatment? YES NO 5. SHIPPING PREFERENCES and INJECTION TRAINING FIRST DOSE: Prescriber Address Patient Address FOLLOW-UP DOSES: Prescriber Address Patient Address I also request supplemental injection training for this patient. 7. NETWK PHARMACY PRESCRIPTION (Please complete steps 1 4 below and sign) Does this patient have documented efficacy failure of adequate trial on Enbrel, Humira, Remicade, Stelara, Cimzia, Simponi, Taltz, or other biologic treatment? YES NO If YES, please indicate which drug(s) and date(s) of usage. Enbrel From: To: Humira From: To: Remicade From: To: Stelara From: To: Cimzia From: To: Simponi From: To: Taltz From: To: Other From: To: 6. COVERED UNTIL YOU RE COVERED* FREE MEDICATION PRESCRIPTION (optional) Covered Until You re Covered Program: Eligible patients must have commercial insurance, a valid prescription for COSENTYX, and a denial of insurance coverage based on a prior authorization request. Program requires the submission of an appeal within 90 days after enrollment. Please complete the full Service Request Form, including steps 1 4 below and sign. See Program Terms and Conditions on Page 3. STEP 1: SENSEADY PEN PREFILLED SYRINGE Preferred Specialty Pharmacy (optional): STEP 1: SENSEADY PEN PREFILLED SYRINGE STEP 2: Inject 300-mg dose (2 injections of 150 mg) Inject 150-mg dose STEP 2: Inject 300-mg dose (2 injections of 150 mg) Inject 150-mg dose STEP 3: INITIAL WEEKLY LOADING DOSE? (Weeks 0, 1, 2, 3, and 4) YES NO STEP 4: # OF MONTHLY REFILLS? (once every 4 weeks) PRESCRIBER CERTIFICATION I certify that the above therapy is medically necessary and that the information provided is accurate to the best of my knowledge. I certify that I am the prescriber who has prescribed COSENTYX to the previously identified patient and that I provided the patient with a description of the COSENTYX Connect Personal Support Program. I authorize the COSENTYX Connect Personal Support Program to act on my behalf for the purposes of transmitting this prescription to the appropriate pharmacy designated by the patient utilizing their benefit plan. STEP 3: INITIAL WEEKLY LOADING DOSE? (Weeks 0, 1, 2, 3, and 4) YES NO STEP 4: # OF MONTHLY REFILLS? (once every 4 weeks) PRESCRIBER CERTIFICATION I certify that the above therapy is medically necessary and that the information provided is accurate to the best of my knowledge. I certify that I am the prescriber who has prescribed COSENTYX to the previously identifi ed patient and that I provided the patient with a description of the COSENTYX Connect Personal Support Program. I authorize the COSENTYX Connect Personal Support Program to act on my behalf for the purposes of transmitting this prescription to the appropriate pharmacy. I understand that the Covered Until You re Covered Program is designed to support patients who are denied insurance coverage for COSENTYX for up to two years until such coverage is secured, and I confi rm that I will support the above identifi ed patient in seeking to secure such coverage as I deem appropriate. PRESCRIBER SIGNATURE PRESCRIBER SIGNATURE (No Stamp Allowed) (No Stamp Allowed) Page 1 of 3 12/17 T-COS-1351988
SERVICE REQUEST FM (SRF) AND PRESCRIPTIONS PHONE: 1-844-267-3689; FAX: 1-844-666-1366 Please read the following carefully, then sign and date where indicated on page 1. Patient Authorization I give permission for my healthcare providers (HCPs), pharmacies, health insurer(s), third-party contractors, and service providers to disclose my personal information, including information about my insurance, prescriptions, medical condition, and health ( Personal Information ) to Novartis Pharmaceuticals Corporation, its affiliates, business partners, and agents (together, the Novartis Group ) so that the Novartis Group can (i) help to verify or coordinate insurance coverage or otherwise obtain payment for my treatment with COSENTYX, (ii) coordinate my receipt of, and payment for COSENTYX, (iii) facilitate my access to COSENTYX, (iv) provide me with information about COSENTYX, disease awareness and management programs, and educational materials, (v) manage the COSENTYX Connect Personal Support Program, (vi) provide me with adherence reminders and support, and (vii) conduct quality assurance, surveys, and other internal business activities in connection with the COSENTYX Connect Personal Support Program. I give permission to the Novartis Group to disclose my Personal Information to my HCPs, pharmacies, health insurer(s), caregivers, and other third-party contractors or service providers for the purposes described above. I understand that my pharmacy, health insurer(s), and healthcare providers may receive remuneration (payment) from Novartis Pharmaceuticals Corporation in exchange for disclosing my Personal Information to Novartis Pharmaceuticals Corporation 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 1-888-NOW-NOVA (1-888-669-6682) or by writing to the Customer Interaction Center, Novartis Pharmaceuticals Corporation, One Health Plaza, East Hanover, NJ 07936-1080. 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 COSENTYX Connect Personal Support Program. If I revoke this authorization, the Novartis Group 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 disclosures 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 COSENTYX Connect Personal Support Program may change or end at any time without prior notification. I understand that I may receive a copy of this authorization. I agree to be contacted by the Novartis Group by mail, e-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. (continued on last page) Page 2 of 3 T-COS-1351988
SERVICE REQUEST FM (SRF) AND PRESCRIPTIONS PHONE: 1-844-267-3689; FAX: 1-844-666-1366 I also agree to be contacted by the Novartis Group and on its behalf by telephone calls and text messages made by using an automatic telephone dialing system or prerecorded voice at the number(s) provided on the Service Request Form for all non-marketing purposes including, but not limited to, sending me materials and asking for my participation in surveys. I confirm that I am the subscriber for the telephone number(s) provided and the authorized user for the e-mail address(es) provided, and I agree to notify the Novartis Group 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 Novartis Pharmaceuticals Corporation 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 e-mail and cell phone cannot be secured against unauthorized access. Co-pay Assistance Program Terms and Conditions I understand that this offer is only valid for those with commercial insurance and who have a valid prescription. I understand that this offer is not valid under Medicare, Medicaid, or any other federal or state program (eg, VA, DoD, Tricare), for cash-paying patients, where product is not covered by patient s commercial insurance, or where the plan reimburses the patient for the entire cost of his/her prescription drug. I also understand that this offer is not valid where prohibited by law and is only valid in the United States and Puerto Rico. Finally, Novartis requires patients to annually re-enroll and re-attest to the program terms and conditions. We may use the information you provide to contact you to remind you that your co-pay assistance is about to expire and to confirm your eligibility to continue participating in co-pay assistance. *Covered Until You re Covered Program Terms and Conditions Eligible patients must have commercial insurance, a valid prescription for COSENTYX, and a denial of insurance coverage based on a prior authorization request. Program requires the submission of an appeal of the coverage denial within the first 90 days of enrollment in order to remain eligible. Program provides initial 5 weekly doses (if prescribed) and monthly doses for free to patients for up to two years or until they receive insurance coverage approval, whichever occurs earlier. Program is not available to patients whose medications are reimbursed in whole or in part by Medicare, Medicaid, Tricare, or any other federal or state program. Patients may be asked to re-verify insurance coverage status during the course of the program. No purchase necessary. Program is not health insurance, nor is participation a guarantee of insurance coverage. Limitations may apply. Enrolled patients awaiting coverage for COSENTYX after two years may be eligible for a limited Program extension. Novartis Pharmaceuticals Corporation reserves the right to rescind, revoke, or amend this Program without notice. Program enrollment must occur by 12/31/18. Page 3 of 3 Novartis Pharmaceuticals Corporation East Hanover, New Jersey 07936-1080 2017 Novartis Printed in USA 12/17 T-COS-1351988