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.
Enrollment Form and Prescription Information Complete and fax this form to 1-800-752-5896 For assistance or additional information, call 1-877-877-3536, Monday-Friday, 8:00 am-8:00 pm, ET 1. Patient Information 2. Prescriber Information NAME (First, MI, Last) E-MAIL DOB (MM/DD/YYYY) ADDRESS CITY STATE ZIP CODE HOME PHONE CELL PHONE WORK PHONE BEST TIME TO CONTACT (Complete caregiver information only if you authorize or prefer that caregiver[s] be contacted in place of you) CAREGIVER/CONTACT HOME PHONE CELL PHONE WORK PHONE BEST TIME TO CONTACT PRESCRIBER NAME (First, Last) SPECIALTY PRACTICE NAME OFFICE CONTACT ADDRESS CITY STATE ZIP CODE E-MAIL PHONE FAX MEDICAID/MEDICARE PROVIDER# TAX ID# STATE LICENSE# UPIN/NPI# 3. Insurance Information (Complete this section or provide a copy of prescription insurance card) PRIMARY INSURANCE SECONDARY INSURANCE CARDHOLDER CARDHOLDER RELATIONSHIP TO CARDHOLDER RELATIONSHIP TO CARDHOLDER EMPLOYER INS. CO. PHONE EMPLOYER INS. CO. PHONE POLICY# POLICY# GROUP# GROUP# PRESCRIPTION DRUG INSURER CARD/BIN# PHONE 4. Patient Authorization for YOU&i Support Program My signature below certifies that I have read, understand, and agree to the Patient Authorization to release my protected health information to Pharmacyclics LLC, an AbbVie Company, and Janssen Biotech, Inc., and companies working on their behalf, as defined on the attached Patient Copy. I authorize the YOU&i Support Program to leave a message, including the prescription name IMBRUVICA (ibrutinib) pills, if I am unavailable when they call. This program is only intended for US residents. I certify that I am a US resident. q Yes q No q Yes q No PATIENT SIGNATURE DATE PATIENT NAME If patient cannot sign, patient s legally authorized representative must sign below. PATIENT NAME BY Signature of person legally authorized to sign for patient NAME OF PERSON LEGALLY AUTHORIZED TO SIGN RELATIONSHIP PHONE NUMBER 5. Prescription Information (If requesting benefits investigation only, do not complete this section) Rx: o IMBRUVICA (ibrutinib) 560 mg tablet o IMBRUVICA (ibrutinib) 420 mg tablet o IMBRUVICA (ibrutinib) 280 mg tablet o IMBRUVICA (ibrutinib) 140 mg tablet o IMBRUVICA (ibrutinib) 70 mg capsule Directions: 1 pill taken orally once daily Qty: 28 pills ICD Diagnosis Code: NAME (if different than above) ADDRESS CITY STATE ZIP CODE PRESCRIBER SIGNATURE REQUIRED. I certify that therapy with IMBRUVICA is medically necessary for this patient. I will be supervising the patient s treatment accordingly and I have reviewed the current IMBRUVICA Prescribing Information. PRESCRIBER SIGNATURE DATE SUPERVISING PHYSICIAN NAME (if applicable) SPECIAL NOTE: The prescription is only valid if received by fax. If not faxed, prescription must be submitted on state-specific blank, if applicable for your state. 6. Provider Preferred Specialty Pharmacy As the treating physician, I have discussed preference for a Specialty Pharmacy (SP) with this patient. This patient prefers use of the SP indicated below. I authorize Pharmacyclics LLC and Janssen Biotech, Inc., and its representatives to fax this prescription to: 1. The SP designated as checked below, provided it is approved by this patient s plan. 2. An SP approved by the patient s plan, if the SP designated is not a plan-approved SP. 3. Any SP approved by this patient s plan, if there is no preferred SP indicated. q Avella Specialty Pharmacy q Biologics q Diplomat Specialty Pharmacy q Onco360 q Approved in-office dispensing pharmacy
By providing your information and information about your patient on the front of the YOU&i Support Program Enrollment Form, you are requesting the services described on this form. The information you provide will only be used by Pharmacyclics LLC and Janssen Biotech, Inc., our affiliates, and our service providers involved in delivering these services. You may withdraw your request for these services by calling 1-877-877-3536. Our Privacy Policy, available at www.pharmacyclics.com/privacy-policy, governs the use of the information you provide. By providing the information and submitting this form, you indicate you read, understand, and agree to these terms. Patient insurance benefit investigation is provided as a service by the support services administrator under contract for Pharmacyclics LLC and Janssen Biotech, Inc. In this regard, the support services administrator assists healthcare professionals in the determination of whether treatment could be covered by the applicable third-party payer based on coverage guidelines provided by the payer and patient information provided by the healthcare provider under appropriate authorization following the provider s exclusive determination of medical necessity. Importantly, insurance verification is the ultimate responsibility of the provider. Third-party reimbursement is affected by many factors. Therefore, the support services administrator, and Pharmacyclics LLC and Janssen Biotech, Inc. make no representation or guarantee that full or partial insurance reimbursement or any other payment will be available. This information is provided as an information service only. While the support services administrator tries to provide correct information, it and Pharmacyclics LLC and Janssen Biotech, Inc. make no representations or warranties, expressed or implied, as to the accuracy of the information. In no event shall the support services administrator, or Pharmacyclics LLC and Janssen Biotech, Inc. or its employees or agents be liable for any damages resulting from or relating to the services. All providers and other users of this information agree that they accept responsibility for the use of this service. Pharmacyclics LLC and Janssen Biotech, Inc. assumes no responsibility for, and does not guarantee, the quality, scope, or availability of the services including, but not limited to, reimbursement support services, patient education, and other support services. Each provider, not Pharmacyclics LLC and Janssen Biotech, Inc., is responsible for the services they provide. These support services have no independent value to providers apart from the product and are included within the cost of the product. Before prescribing IMBRUVICA (ibrutinib), please see full Prescribing Information available at www.imbruvica.com.
PATIENT COPY PATIENT AUTHORIZATION for the YOU&i Support Program brought to you by Pharmacyclics LLC and Janssen Biotech, Inc. My signature on the YOU&i Support Program Enrollment Form confirms that I authorize each of my physicians, pharmacists, including any specialty pharmacy and/or self-dispensing office, patient assistance program pharmacy, which receives my prescription for IMBRUVICA (ibrutinib) and other healthcare providers (together, Healthcare Providers ) and each of my health insurers (together, Insurers ) to disclose my protected health information, including, but not limited to, medical records and treatment, my health insurance coverage, my name, address, telephone number, insurance plan, and/or group numbers (together, Health Information ) to Pharmacyclics LLC and Janssen Biotech, Inc. and its affiliated companies, vendors, agents, collaboration partners, and representatives (collectively, Pharmacyclics LLC and Janssen Biotech, Inc. ), and including providers of alternate sources of funding for prescription drug costs, and other service providers supporting access programs for Healthcare Providers and Patients for the purposes described below. Specifically, I authorize disclosure of my Health Information in order for Pharmacyclics LLC and Janssen Biotech, Inc. to receive, use, and disclose my Health Information in order to i) enroll me in, and contact me (and/or the person legally authorized to sign on my behalf, or the caregiver(s) I have authorized to be contacted on my behalf), ii) provide me (and/or the person legally authorized to sign on my behalf, or the caregiver(s) I have authorized on my behalf) with educational materials, nursing educational calls (if selected), and other support services related to IMBRUVICA, iii) verify, investigate, assist with, and coordinate my coverage for IMBRUVICA with my insurers, iv) coordinate prescription fulfillment, v) assist with analyses related to the quality, efficacy, and safety of IMBRUVICA, and vi) provide me with other product informational materials, treatment reminders, or surveys about my treatment experience with IMBRUVICA. I also understand that specialty pharmacies and/or self-dispensing offices may receive direct or indirect compensation from Pharmacyclics LLC and Janssen Biotech, Inc. for the use or disclosure of my personal information to the YOU&i Support Program for the above-stated purposes. I understand that once my Health Information has been disclosed to Pharmacyclics LLC and Janssen Biotech, Inc., federal and state privacy laws may no longer protect it. However, Pharmacyclics LLC and Janssen Biotech, Inc. agree to protect my Health Information by using and disclosing it only for the purposes described in this authorization or as permitted by law. My choice about whether to sign will not change the way my Healthcare Providers or Insurers treat me. If I refuse to sign the Enrollment Form, or revoke my authorization later, I understand that this means I will not be able to participate or receive assistance from the Pharmacyclics LLC and Janssen Biotech, Inc. Patient Support Program. I understand that I may cancel (revoke) this Authorization at any time by mailing a request to 2730 S Edmonds Lane, Suite 300, Lewisville, TX 75067, calling 1-877-877-3536 or by going to www.imbruvica.com/unsubscribe. I understand that revoking this authorization will end further uses and disclosures of my information by the parties identified above except to the extent those uses and disclosures have been made in reliance upon this authorization and as permitted by applicable law. This authorization expires 3 years from the date indicated on the Patient Authorization section, unless I revoke it earlier. I am entitled to receive a copy of this authorization. Please read the accompanying Important Product Information for IMBRUVICA and discuss any questions you have with your doctor.