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 R PCN: NMEDS R 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.
Takeda Patient Assistance Program P.O. Box 5727, Louisville, Kentucky 40255-0727 Phone: 1-800-830-9159 Fax: 1-800-497-0928 CAN I APPLY? At Takeda, we believe all patients should have access to the medications prescribed by their healthcare providers. We also understand that some patients may have financial situations that make it difficult to pay for their prescriptions. Help At Hand (the Program) provides assistance for people who have no insurance or who do not have enough insurance and need help getting their Takeda medicines. All applications are reviewed on a case-by-case basis in accordance with program criteria. To be eligible, you should: q Be a legal resident in the United States q Not have health coverage, or not have enough coverage to obtain your Takeda medication q Have a household income equal to or less than 4 times the Federal Poverty Level (for more information on Federal Poverty Levels, visit http://www.aspe.hhs.gov/poverty/index.cfm) q Not have access to alternate sources of coverage or funding CHECKLIST FOR SUBMITTING APPLICATION q Complete Sections 1, 4, 5, and 6, including signatures q Attach current proof of income as outlined in Section 4 q Have healthcare provider complete and sign Sections 2 and 3 q Fax or mail the completed application and all documentation to the address above USE THIS APPLICATION IF YOU HAVE A PRESCRIPTION FOR ONE OF THESE MEDICATIONS AMITIZA (lubiprostone) COLCRYS (colchicine, USP) DEILANT (dexlansoprazole) KAZANO (alogliptin and metformin HCl) NESINA (alogliptin) OSENI (alogliptin and pioglitazone) PREVACID SOLUTAB (lansoprazole orally disintegrating tablet) ROZEREM (ramelteon) TRINTELLI (vortioxetine) ULORIC (febuxostat) IMPORTANT: Please go to next page. Call 1-800-830-9159 if you need help. Patient Assistance Program representatives are available Monday through Friday, 8:30 a.m. to 6:00 p.m. ET PLEASE PRINT CLEARLY IN BLACK OR BLUE INK 2017 Takeda Pharmaceuticals America, Inc. 05/17
PLEASE PRINT CLEARLY IN BLACK OR BLUE INK Patient Name: DOB: SECTION 1: PATIENT INFORMATION First Name: Last Name: Home Address: City: State: ZIP Code: Preferred Daytime Phone Number: Social Security Number (or Green Card or Visa Number): Date of Birth (MM/DD/YYYY): q Male q Female U.S. Resident: q Yes q No Deliver Medication To: q Patient q Healthcare Provider (Delivery will be to patient unless otherwise indicated.) SECTION 2: HEALTHCARE PROVIDER INFORMATION Last Name: First Name: Clinic Name (if applicable): Address: City: State: ZIP Code: State License Number: Phone: Fax: List all current patient medications below: Is patient allergic to any medications? q YES (please list below) q NO SECTION 3: PRESCRIPTION INFORMATION (NJ and NY physicians please attach appropriate prescription) TAKEDA PRODUCT NAME/STRENGTH DIRECTIONS DAYS SUPPLY REFILLS (circle) IMPORTANT: Please go to next page. Call 1-800-830-9159 if you need help. 90 days 1 2 3 90 days 1 2 3 My signature certifies that prescribed therapy is medically necessary for the subject patient and that I will be supervising the patient s treatments. Additionally, I certify that if the product is sent to my office on behalf of the patient, I understand that it must be used for the patient listed on this application, and not be resold or offered for sale or trade, nor shall the patient nor any third-party payer, Medicare or Medicaid be charged for this product. Healthcare Provider Signature (Stamped Signatures NOT ACCEPTED) AMITIZA is a trademark of Sucampo Pharmaceuticals, Inc. registered with the U.S. Patent and Trademark Office and used under license by Takeda Pharmaceuticals America, Inc. COLCRYS is a trademark of Takeda Pharmaceuticals U.S.A., Inc., registered with the U.S. Patent and Trademark Office and used under license by Takeda Pharmaceuticals America, Inc. DEILANT and DEILANT (with design) are trademarks of Takeda Pharmaceuticals U.S.A., Inc., registered in the U.S. Patent and Trademark Office and used under license by Takeda Pharmaceuticals America, Inc. NESINA, OSENI and KAZANO are trademarks of Takeda Pharmaceutical Company Limited registered with the U.S. Patent and Trademark Office and used under license by Takeda Pharmaceuticals America, Inc. PREVACID is a trademark registered in the U.S. Patent and Trademark Office and SoluTab is a trademark of Takeda Pharmaceuticals U.S.A., Inc. and used under license by Takeda Pharmaceuticals America, Inc. ROZEREM is a trademark of Takeda Pharmaceutical Company Limited registered with the U.S. Patent and Trademark Office and used under license by Takeda Pharmaceuticals America, Inc. Date TRINTELLI is a trademark of H. Lundbeck A/S, trademarks are used under license by Takeda Pharmaceuticals America, Inc. ULORIC is a trademark of Teijin Pharma Limited registered with the U.S. Patent and Trademark Office and used under license by Takeda Pharmaceuticals America, Inc.
PLEASE PRINT CLEARLY IN BLACK OR BLUE INK Patient Name: DOB: SECTION 4: INSURANCE AND INCOME Do you have prescription drug insurance from: (check all that apply) q None q VA/Military benefits q Health exchange plan q Employer supplied/private coverage q Medicare Part D (Part D ID number: ) q Medicaid q Although I have prescription drug coverage as above, financial hardship makes it difficult to obtain my Takeda medication through this plan. Number of people in household* Total yearly household* income: $ *Household = you, spouse and dependents Have you received Social Security Disability Income for at least two years? q Yes q No To verify your income, please include a copy of one of the following: q Last year s federal income tax return(s) for yourself, your spouse and your dependents q Social Security Yearly Benefits Statement (SSA-1099) or q All household income statements from the last month If these documents do not accurately reflect your current financial status, please send documentation of your current income or unemployment. I declare and affirm that the information provided by me on this application form is true and accurate. I give consent to the Program to disclose my enrollment in the Program as needed to comply with legal and regulatory obligations. I agree to notify the Program immediately, in writing, if my prescription drug coverage changes in any way. Patient Signature (Stamped Signatures NOT ACCEPTED) Date: SECTION 5: IF YOU HAVE OR MAY BE ELIGIBLE FOR MEDICARE PART D PLEASE COMPLETE THE FOLLOWING. PLEASE READ THE FOLLOWING CAREFULLY AND SIGN BELOW 1. I agree to notify the Program immediately, in writing, if my prescription drug coverage changes in any way. 2. I will not seek or accept reimbursement from any health or prescription coverage plan, including Medicare Part D plan, for medication received from the Program. 3. I understand that if I am eligible or enrolled in a Medicare Part D plan, I will receive the requested medication from the Program for the remainder of the enrollment calendar year* for which my application was approved, and I will not seek the requested medication from my Medicare Part D plan for the remainder of the enrollment calendar year.* 4. If I am enrolled in Medicare Part D, I will not seek true out-of-pocket (TrOOP) credit for any medication received from the Program because I understand that medication received from the Program will not count toward my TrOOP. 5. If I am enrolled in Medicare Part D, I agree to notify my Medicare Part D plan that I will receive my Takeda medication for free until the end of the year through the Program. *Enrollment calendar year is the calendar year for which this application is being submitted. Patient Signature (Stamped Signatures NOT ACCEPTED) Date: IMPORTANT: Please go to next page. Call 1-800-830-9159 if you need help.
PLEASE PRINT CLEARLY IN BLACK OR BLUE INK Call 1-800-830-9159 if you need help. Patient Name: DOB: SECTION 6: PATIENT HIPAA AUTHORIZATION AND CERTIFICATION PLEASE READ THE FOLLOWING STATEMENT CAREFULLY AND SIGN BELOW I request and authorize my healthcare provider (listed in Section 2) and my health insurance company (if any) to disclose to Takeda Pharmaceuticals America, Inc. (Takeda) and its affiliated companies, or third-party contractors assisting Takeda in connection with the Takeda Patient Assistance Program (Program), all personal information relating to my medical condition, treatment and insurance coverage needed to determine my eligibility and administer my participation in the Program. I may refuse to sign this authorization. If I refuse, I will not be able to participate in the Program, but it will not affect my ability to obtain medical treatment, my ability to seek payment for treatment, or affect my insurance enrollment or eligibility for insurance benefits. I may cancel this authorization at any time by mailing a letter of cancellation to Takeda at the address listed at the top of this application form. If I cancel this authorization, I will no longer be allowed to participate in the Program. Cancelling this authorization will prohibit disclosures of my personal information after the date the cancellation letter is received and processed by Takeda, but will not affect disclosures made before that time. I understand that once my personal information is disclosed to Takeda or its contractors, federal privacy laws may no longer protect the information from further disclosure. However, my personal information will not be used or disclosed by Takeda or its contractors for any purpose other than to determine my eligibility and to administer my participation in the Program. This authorization expires at the end of my participation in the Program. I certify that the information on this form is accurate and complete to the best of my knowledge. I agree that Takeda and its contractors may also contact my health insurer to verify my insurance information. Patient Signature (Stamped Signatures NOT ACCEPTED) Date: What happens next? You and/or your healthcare provider will receive an answer from the Takeda Patient Assistance Program within five to seven days after we receive your application. Please call 1-800-830-9159 if you have questions. Representatives are available Monday through Friday from 8:30 a.m. to 6:00 p.m. ET Quantity of bottles supplied may vary based on patient prescription. This program, as well as all Takeda Pharmaceuticals America, Inc. programs, can be discontinued or changed at any time without notice at the discretion of Takeda Pharmaceuticals America, Inc. Takeda Patient Assistance Program P.O. Box 5727, Louisville, Kentucky 40255-0727 Phone: 1-800-830-9159 Fax: 1-800-497-0928 2017 Takeda Pharmaceuticals America, Inc. 05/17