Patient Services and Support

Patient Services and Support BENLYSTA Gateway: Providing resources and information to meet changing access needs 1-877-4-BENLYSTA (1-877-423-6597) Select option 1 for BENLYSTA Gateway Monday-Friday, 8 am to 8 pm, ET www.benlystagatewayonline.com

For Reimbursement Information BENLYSTA Gateway Offers: Patient-Centered Access Services Patient-specific benefits investigation Re-verification of benefits for annual health plan changes, if appropriate Prior authorization research Coding and billing details Prescription referral triage to an in-network Specialty Pharmacy Prior authorization tracking assistance Claims appeals tracking assistance Real-time patient status Provider portal to assist in managing enrolled patients Estimate of insurance coverage and cost-share information Eligibility determinations for the BENLYSTA Co-pay Program* Eligibility determinations for the Patient Assistance Program for uninsured patients Alternative coverage research BENLYSTA Gateway provides informational resources for patients and healthcare professionals; specific eligibility requirements are determined by the payer; therefore, patients and healthcare providers should consult directly with payers. *Subject to eligibility requirements.

BENLYSTA Gateway Can Help With 1) Enrollment Complete Enrollment Form to Initiate Services 1) Enrollment 2) Investigation Obtain physician and patient signatures on BENLYSTA Gateway Services Form and fax to [1-877-850-9901]. Enrollment forms can also be submitted via the BENLYSTA Gateway Portal at benlystagatewayonline.com. Note: if submitting an Enrollment form through this Portal, be sure to attach a prescription and copies of the patient s prescription cards to ensure that BENLYSTA Gateway has the information needed and can process in accordance with state prescribing laws. 2) Investigation 3) Acquisition Benefits Investigation 4) Reimbursement BENLYSTA Gateway offers patient-specific benefits investigation. Please note that investigations do not guarantee a result and it is the provider s responsibility to check with the payer. BENLYSTA Gateway can: Work directly with insurance companies to obtain specific coverage information Check Payer s prior authorization requirements Determine estimated patient out-of-pocket responsibility BENLYSTA Gateway will contact you to explain estimated projected coverage and to discuss patients eligibility for co-pay assistance.

2) Investigation (cont d) Prior Authorization (PA) Research and Support Financial Assistance Evaluation BENLYSTA Gateway can: Research plan requirements Outline steps required for obtaining a PA from the patient s plan Obtain unique and plan-specific PA forms (where applicable) BENLYSTA Gateway can also follow up with the plan to help determine the status of the PA submission (if requested). BENLYSTA Gateway can evaluate the potential for co-pay assistance options, including the BENLYSTA Co-pay Program.* $0 Co-pay for eligible patients (Eligibility restrictions and maximum limits apply.) Up to a total of [$9,000] annually. Remember, BENLYSTA Gateway cannot complete PA forms or submit related information to plans. Instead, it is the responsibility of the office and prescribing physician to provide the plan with patient-specific clinical documentation. For commercially insured and uninsured patients who are unable to afford their cost-share associated with BENLYSTA and do not qualify for the Patient Assistance Program, BENLYSTA Gateway can help determine eligibility for the BENLYSTA Co-pay Program. Those not eligible include patients with or eligible for a state- or federal government-funded medical or prescription insurance plan such as Medicare, Medicaid, VA, or Tricare. BENLYSTA Gateway can also help eligible uninsured patients obtain access to BENLYSTA free of charge through a Patient Assistance Program and arrange for the shipment directly to the site of service. *The BENLYSTA Co-pay Program is not insurance. The BENLYSTA Co-pay Program is for private commercially insured patients or uninsured patients who do not qualify for the BENLYSTA Patient Assistance Program. The program covers the patient s out-of-pocket costs for BENLYSTA up to a total of [$9,000] annually, but does not cover co-pays for doctor s office visits or cost of administration. To be eligible, the patient must be a US resident (including the District of Columbia and Puerto Rico).

3) Acquisition 4) Reimbursement BENLYSTA is available through a variety of options Coding 1. Specialty Distributor. Clinics can contact one of the approved specialty distributors below. [ASD Specialty Healthcare 800-746-6273] [Besse Medical 800-543-2111] [Cardinal Health Specialty 866-476-1340] [CuraScript 800-942-5999] [McKesson Specialty 800-482-6700] [McKesson Plasma and Biologics 877-625-2566] [Metro-Medical Supply, Inc 800-768-2002] [Oncology Supply 800-633-7555] 2. Wholesaler. All GSK-authorized wholesalers are eligible to access BENLYSTA provided they service eligible customer classes of trade. 3. Specialty Pharmacy Provider. Patients may need to use a network of specialty pharmacies. Please contact the payer for the full list of the network specialty pharmacies. The BENLYSTA Gateway or Payer Relations Manager (PRM) may also be able to provide assistance. BENLYSTA Gateway can evaluate what acquisition alternatives exist based on the patient s insurance. Should the patient be referred to an alternate site of care, contact your PRM to discuss coordination of care considerations. BENLYSTA Gateway can provide information about relevant codes for BENLYSTA, including product codes, procedure codes, diagnosis codes, NDC numbers, and revenue codes (as applicable). Coding requirements often can vary by site of care and Payer type. Claims and Appeals Support Claim submission requirements can vary by plan. BENLYSTA Gateway can: Share examples of CMS 1500 and 1450 claim forms Outline site-of-care differences in coding services Provide Payer-specific information BENLYSTA Gateway can also provide appeals research if necessary; BENLYSTA Gateway cannot author appeal letters on behalf of physicians. Services include: Researching the appeals requirements for specific Payers Faxing a sample Letter of Medical Necessity to the provider s office Tracking status of appeals once submitted The BENLYSTA Gateway program cannot submit claim forms directly to Payers.

Benefits Verification Co-pay Program Prior Authorization Assistance Patient Assistance Program (PAP) for Uninsured Patient Claims Assistance SP Triage Last name: First name: Date of birth: Gender: Female Male Street: City: State: ZIP: Home phone: ( ) Work/cell phone: ( ) Alternate contact name: E-mail: Alternate contact phone: ( ) Relationship to patient: PRIMARY insurance: SECONDARY insurance: Rx Card (PBM): Policyholder first name: Private Commercial Private Commercial ID #: Policyholder last name: Medicare/Medicaid TRICARE Medicare/Medicaid TRICARE BIN #: Policyholder date of birth: Phone: Phone: PCN #: Employer: Policy ID #: Policy ID #: Group #: Relationship to patient: Group #: Group #: Phone: BENLYSTA for intravenous use (IV) BENLYSTA for subcutaneous use (SC) Dose: Frequency: Date to begin dosing regimen: Patient diagnosis and ICD-10 (not required for uninsured PAP applicants): Anti-Nuclear Antibody (ANA) Anti ds-dna Level SELENA-SLEDAI Score Concomitant Medications (please attach) Prescriber s last name: Prescriber s first name: Practice name: Specialty: Street: City: State: ZIP: Office contact name: Phone: ( ) Fax: ( ) Prescriber tax ID: Prescriber NPI #: Group NPI #: Prescriber State License # (for uninsured PAP applicants only): Are you the prescribing physician? Yes No If no, provide name of prescribing physician: How will BENLYSTA be acquired? Buy and Bill Specialty Pharmacy Undecided Site of administration: Prescribing physician s office Other physician s office Hospital outpatient department Alternative Site of Care (ASOC) Patient administered If administration site is different than site of prescribing physician, please complete the following: Administering practice/facility name: Administering physician s last name: Administering physician s first name: Street: City: State: ZIP: Administering site contact: Phone: ( ) Fax: ( ) Administering site TAX ID: Administering site NPI #: New Restart Continuing Next treatment date/date needed by: Specialty Pharmacy selection is subject to health plan requirements. Specialty Pharmacy requested: Specialty Pharmacy ship to: Patient Address (BENLYSTA SC only) Prescribing physician s office Administering physician s office HOPD ASOC MEDICATION STRENGTH/FORM QTY DIRECTIONS FOR ADMINISTRATION REFILL BENLYSTA SC 200 mg in a 1-mL single dose autoinjector (box of 4) BENLYSTA SC 200 mg in a 1-mL single dose prefilled glass syringe (box of 4) BENLYSTA IV 120 mg in a 5-mL single-use vial BENLYSTA IV 400 mg in a 20-mL single-use vial 2017 GSK group of companies. I certify that the information provided above is true and that BENLYSTA is being prescribed for the patient listed above. I hereby certify that, for any insured patient seeking All rights reserved. Printed in USA. co-pay 8 18 221R0 assistance J uly 2017under the Co-pay Program, in the absence of financial support from such program, any applicable co-pay, coinsurance or other out-of-pocket cost for BENLYSTA would be collected from the patient upon treatment. I appoint the BENLYSTA Gateway, on my behalf, to convey this prescription to the dispensing pharmacy, to the extent permitted under state law. Special Note: Prescribers in all states must follow applicable laws for a valid prescription. For prescribers in states with official prescription form requirements, please submit an actual prescription along with this enrollment form. [NY] prescribers may need to submit an electronic prescription to the specialty pharmacy. Page 1 of 4 Requesting Services from BENLYSTA Gateway 1) Obtain Form and Select Services 3) Confirm Enrollment Ask your GSK Account Specialist or Payer Relations Manager (PRM) for copies of the Services Form or download a version from Benlystahcp.com. Check the appropriate boxes to request that BENLYSTA Gateway performs these services. Complete all other fields. BENLYSTA Gateway will send a fax to your office to confirm that the Services Form was received and is being processed. Call BENLYSTA Gateway directly at 1-877-423-6597 (Option 1) if you do not receive this fax confirmation. SERVICES REQUESTED (Check all that apply) Benefits Verification Co pay Program Prior Authorization Assistance Patient Assistance Program (PAP) for Uninsured Patient Claims Assistance SP Triage 2) Complete and Fax Form 4) Review Results Make sure that both the provider and the patient sign the form. Fax the completed Services Form, plus copies of your patient s medical and pharmacy insurance cards, to [1-877-850-9901]. Services Form Enrollment Instructions for BENLYSTA for subcutaneous use (SC) BENLYSTA for intravenous use (IV) For assistance with any questions, please call 1-877-4-BENLYSTA (1-877-423-6597), M onday through Friday from 8AM to 8PM ET. IMPORTANT: The Services Request Form cannot be fully processed without both the patient and provider signing and dating the form. Services Form for BENLYSTA Gateway offers the following services to patients and healthcare providers (HCPs) as described BENLYSTA below. for subcutaneous use (SC) Benefits Investigation & Prior Authoriz ation (PA) Research: BENLYSTA Gateway investigates the patient s BENLYSTA medical and for prescription intravenous benefits use (IV) as well as coverage rules for the patient s insurance plan, including PA or predetermination criteria. Please complete the form, sign, and FAX back both pages to 1-877-850-9901 IMPORTANT: BENLYSTA Gateway may not submit PA requests to a Payer. For assistance with any questions, please call 1-877-4-BENLYSTA (1-877-423-6597) Co- pay Program: If a commercially insured SERVICES patient REQUESTED requests it, BENLYSTA (Check all Gateway that apply) researches the patient s eligibility for the BENLYSTA Co-pay Program. Please be aware, this program does not constitute health insurance. Patient Assistance Program (PAP) for Uninsured Patients: Uninsured patients may be eligible to receive BENLYSTA free of charge. If an uninsured patient requests it, BENLYSTA Gateway researches the patient s eligibility for PAP. Patients must also complete the PAP Applicants Only section on PATIENT INFORMATION the last page of this form. Specialty Pharmacy (SP) Triage: If the product will be ordered through a specialty pharmacy, BENLYSTA Gateway will send the prescription referral to a specialty pharmacy that is in the patient s network. SP selection varies based on third-party payer requirements and patient cost-share. Patient and provider preferences will be considered where possible. If the patient has applied, and is subsequently approved, for co-pay assistance, BENLYSTA Gateway also sends the patient s co-pay information to the SP. Prior Authoriz ation Track ing Assistance: INSURANCE BENLYSTA INFORMATION Gateway tracks (Please the status attach of copy a PA of once insurance submitted, card[s]) and if applicable, Medical researches Cards Prescription reasons that Card the PA was denied. Claims & Appeals Track ing Assistance: BENLYSTA Gateway provides details on next steps required for an appeal and tracks an appeal once submitted by the provider. PROVIDER AND/OR PATIENT TO FILL OUT THE FOLLOWING SECTIONS: SERVICES REQUESTED: Check the appropriate boxes at the top of the form to request that BENLYSTA Gateway perform the services requested. Once DIAGNOSIS AND TREATMENT (Prescribed dosing regimen of BENLYSTA) services are completed, BENLYSTA Gateway will call the patient and provider to review the results. A written summary of the results will also be mailed to the patient and faxed to the provider. INSURANCE INFORMATION: The medication may be covered under the medical or pharmacy benefit. Include legible copies (front and back) of the patient s medical and pharmacy insurance card(s). Include primary, secondary, Medicare/Medicaid (if eligible), and pharmacy benefit insurance information to ensure that ALL potential coverage options PHYSICIAN can be explored. INFORMATION PRESCRIBER, ACQUISITION, AND ADMINISTRATION INFORMATION: Please indicate here how the medication will be acquired. Buy and Bill: If the provider will purchase the medication directly for administration in his/her office, choose this option. As described above, BENLYSTA Gateway will investigate the patient s benefits and research Prior Authorization (PA) requirements. Specialty Pharmacy: If the product will be ordered through a specialty pharmacy, please choose this option. If requesting that the prescription referral be triaged to a specialty pharmacy, check the Specialty Pharmacy Triage service at the top of the form and complete the Specialty Pharmacy section. IMPORTANT: Once BENLYSTA Gateway has triaged the referral, the patient and provider should contact the specialty pharmacy directly to inquire about the status of the prescription referral and to coordinate any prior authorization requirements and shipping. It is important for the patient and provider to promptly return calls from the SP to minimize delays in processing the prescription. Hospital Outpatient Department (HOPD)/Alternative Site of Care (ASOC): If the patient will be receiving an infusion at a location other than the provider s office, please choose this option and provide the requested information. Undecided: Select this option if it is not yet determined how the medication will be acquired. BENLYSTA Gateway will investigate the patient s benefits and research PA requirements. PATIENT OR PATIENT S LEGAL GUARDIAN TO FILL OUT THE FOLLOWING SECTIONS: SPECIALTY PHARMACY (complete only if requesting that the medication referral be triaged to Specialty Pharmacy) PATIENT INFORMATION: Please fill out the section completely, including your email address and a phone number where BENLYSTA Gateway may call you to review the results of the benefits investigation. PATIENT AUTHORIZ ATION AND RELEASE TO COLLECT, USE, AND DISCLOSE HEALTH INFORMATION: This allows BENLYSTA Gateway to receive your information in order to provide services. Before signing, please review, understand, and agree to the terms of the authorization and release. PATIENT ASSISTANCE PROGRAM (PAP) APPLICANTS: Patients who would like BENLYSTA Gateway to research their eligibility for PAP should fill out the PAP Applicants Only section. Otherwise, please leave blank. OPTIONAL EDUCATIONAL SUPPORT FOR PATIENTS: Additional resources are available to support patients on their treatment journey with the medication. Patients should express interest by checking the box and providing an email address where they may receive information. PRESCRIBER DECLARATION PRESCRIBER SIGNATURE REQUIRED SUBSTITUTION PERMITTED Date DISPENSE AS WRITTEN Date Have more questions? You can speak with a BENLYSTA Gateway representative. Call: 1-877-4-BENLYSTA (1-877-423-6597), Option 1 Fax: 1-877-850-9901 Monday-Friday, 8 AM to 8 PM, ET Patients will receive a written summary of benefits and a call from BENLYSTA Gateway to review the results. Your office will receive a faxed copy of the summary of benefits and a call from BENLYSTA Gateway to review the results. Remind patients to promptly return any phone calls received from BENLYSTA Gateway. Please see Important Safety Information for BENLYSTA on page 3. Please see full Prescribing Information, including Medication Guide, for BENLYSTA.

1-877-4-BENLYSTA (1-877-423-6597) Select option 1 for BENLYSTA Gateway Monday-Friday, 8 AM to 8 PM, ET www.benlystagatewayonline.com GSKSource.com 2017 GSK group of companies. All rights reserved. Printed in USA. 818115R1 July 2017