NeedyMeds www.needymeds.org Find help with the cost of medicine Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need. REMEMBER - Send your completed application to address on the form, NOT to NeedyMeds. 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. 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 Richard J. Sagall, MD President, NeedyMeds NeedyMeds.org P.O. Box 219 Gloucester, MA 01931 Phone: 978-281-6666 Email: info@needymeds.org www.needymeds.org
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.
SECTION 3 Prescription Information (to be completed by prescribing physician) A valid prescription must be provided by your healthcare professional Physician Full Name: Office Contact Full Name: DEA #: State License #: NPI #: Fax: Exp Date: - - Phone: Address: (No P.O. Box) City: State: Zip: Patient First Name: Patient Last Name: Known Allergies: Concomitant medication(s) patient is taking: Drug Name and Dose Selection (please check appropriate box(es) below), and quantity will be determined by the prescription accompanying this request upon approval. Approvals will be valid for up to 12 months and may periodically require verification. CIMZIA PLEASE INCLUDE A COMPLETE PRESCRIPTION WITH THIS APPLICATION. VIMPAT CV Tablets and Oral Solution BRIVIACT CV Tablets and Oral Solution NEUPRO Transdermal System o CIMZIA Starter Kit o VIMPAT 50mg o BRIVIACT 10mg o NEUPRO 1mg/24hr 6-200mg/mL PFS o VIMPAT 100mg o BRIVIACT 25mg o NEUPRO 2mg/24hr o CIMZIA o VIMPAT 150mg o BRIVIACT 50mg o NEUPRO 3mg/24hr 2-200mg/mL PFS o VIMPAT 200mg o BRIVIACT 75mg o NEUPRO 4mg/24hr o CIMZIA LYO o VIMPAT 10mg/mL o BRIVIACT 100mg o NEUPRO 6mg/24h 2-200mg/mL Vials +2 Vials Sterile Water o BRIVIACT 10mg/mL o NEUPRO 8mg/24hr I certify the information submitted on this application is true and that the prescription drug(s) received as a result of this application will be used to treat ONLY the patient identified above. I will not charge for or sell the prescription drug(s). I further certify that the use of the prescription drug(s) identified above is medically necessary and I will supervise the patient s treatment accordingly. Physician s Signature: Date: Physician signature, MD or DO is required for Briviact CV and Vimpat CV by TX law (PAP pharmacy location) UCB, Inc. UCB Patient Assistance Program 1330 Enclave Parkway Suite 125 Houston, TX 77077 Fax #: (855) 880-5262 Phone #: (877) 785-8906 Email: ucb-pap@cardinalhealth.com 2018, UCB, Inc. All Rights Reserved. All trademarks belong to the UCB Group of Companies. VIMPAT is a registered trademark under license from Harris FRC Corporation. USP-MP.0216-0003(1)
UCB Patient Assistance Program UCB is committed to assisting eligible patients who meet medical and financial criteria with access to the following UCB products. CIMZIA (certolizumab pegol) BRIVIACT (brivaracetam) CV VIMPAT (lacosamide) CV NEUPRO (rotigotine transdermal system) Eligibility Financial assistance for UCB products may be available to patients with a valid prescription from a U.S. licensed health care practitioner. The program is not intended for clinics, hospitals and/or other institutions. The minimum eligibility requirements are as follows: Patient must reside in the United States, the District of Columbia, or Puerto Rico Patient must be uninsured or insured medically but with no prescription coverage Patients with certain Medicare Part D plans may be eligible and can apply to determine eligibility All applications must include a valid prescription from a U.S. licensed healthcare practitioner A patient s total household income cannot exceed 300% of the Federal Poverty Limit (FPL). Detailed information on the current Federal Poverty Limit can be found at the following web URL address: https://www.healthcare.gov/glossary/federal-poverty-level-fpl/ All information provided in this application is subject to verification. If you believe you do not meet the minimum requirements listed above, please contact UCBCares by calling 844-599-CARE (2273) to determine whether other financial resources may be available to you. Application If you believe you meet the minimum requirements for program eligibility, please complete sections 1 and 2 of this application, then have your physician complete section 3. If you believe you do not meet the minimum requirements listed above you may not qualify for the UCB Patient Assistance Program; however, you may contact UCBCares by calling 844-599-CARE (2273) to see if there are other financial resources available to you. Patient or patient representative completes Sections 1 and 2. Proof of income section MUST be completed and signed in order for application to be processed. Please note that proof of income, contained in section 2 titled income information, MUST be completed and signed in order to process your application. Physician completes Section 3 and submits application along with a written prescription for the requested UCB product. 2018 UCB, Inc. All Rights Reserved. All trademarks belong to the UCB Group of Companies. VIMPAT is a registered trademark under license from Harris FRC Corporation. USP-MP.0216-0003(1)
SECTION 1 Patient Information (to be completed by the patient or authorized patient representative) Please print clearly. All fields required. Please note all requested information must be completed in order to avoid delay or possible denial of your application. For applicants requesting VIMPAT CV or BRIVIACT CV, please also include a valid, current driver s license number for the patient/authorized patient representative or an official government issued ID number. Patient First Name: Patient Last Name: Address: City: State: Zip: Phone: Date of Birth: - - Does the patient currently reside in the U.S.?: o Yes or o No Sex: o Male or o Female Social Security #: - - or if applicable Alien ID #: Has the patient previously been enrolled in or approved for the UCB Patient Assistance Program for any product?: o Yes or o No Patient Preferred Language: If the applicant is requesting VIMPAT or BRIVIACT please provide a current, valid driver s license number for the patient/authorized patient representative or official government issued ID number. State: Is this address your shipping address?: o Yes or o No If the answer is No provide shipping address below. Address: City: State: Zip: Do you have prescription drug coverage?: o Yes or o No or o NA If you answered yes above, please answer the questions below. If not applicable please check NA: Prescription Drug Plan (PDP) Name: (e.g., Humana, Blue Shield, United, Aetna, etc.) PDP Contact Number: Do you have Medicare Part D?: o Yes or o No Medicare ID #: ALTERNATE CONTACT: By providing this information, you consent to UCB program administrators sharing or discussing your private health information with this person. Please list no more than two (2) persons authorized to discuss your private health information with UCB program administrators. This may include health care professionals or medical office staff. First and Last Name: Relationship: Phone: First and Last Name: Relationship: Phone: USP-MP.0216-0003(1)
SECTION 2 Income Information Gross Monthly Household Income: Please include your TOTAL GROSS MONTHLY HOUSEHOLD income. If that income comes from salary/wages/dividends, Social Security, supplemental income, disability, unemployment compensation, pension/annuity, alimony/child support, rental income or other (please specify), indicate the dollar amount. If there is NO household income, please submit a letter with this application (signed and dated by the patient or patient s authorized representative) to explain that the patient receives no income. Signature and Date: You or your authorized patient representative must sign and date this application. Proof of income must be submitted with this application. Reported income is subject to verification by consumer credit agencies. List All Sources, Gross Monthly Amounts Salary/Wages: Social Security: Child Support /Alimony: Retirement: Disability: Work Comp: Social Security Pension/ Unemployment: Total Gross Household Monthly Income: Number of persons DEPENDENT upon primary income within the family: Applicant Declarations I certify and promise that: all information provided in this application is complete and accurate, including all copies of documents proving my income; I am authorized to sign this application; I do not have any assistance or insurance that would help pay for my medicines (other than Medicare Part D, if applicable); and I will contact the UCB Patient Assistance Program (Program) if any of my information about my income, financial status, prescription drug coverage, or insurance changes. If audited, I agree to provide the necessary documents to support the information on this application. I understand that completing this application does not ensure that I will qualify for this Program and that the Program assistance will terminate if UCB or its agents become aware of any fraud or if the UCB medication being provided is no longer prescribed for me. I also understand that UCB reserves the right to modify the application form, modify or discontinue the Program, or terminate assistance at any time and without notice. Patient s (or authorized patient representative) Signature: Date: Authorization for Use and Disclosure of Protected Health Information I understand that in order for the UCB Patient Assistance Program to provide me with assistance, it will need to obtain, review, use, and disclose my personal health information (PHI), including information relating to my medical condition and information on my application form. Should an investigative consumer report be utilized, you will have the right to request a complete and accurate disclosure of the nature and scope of the investigation requested and a written summary of your rights under the Fair Credit Reporting Act. I agree to allow the Program to contact me via mail, telephone or email to carry out these services. I authorize my physician(s), pharmacy, and my health plan(s) to share information about me or my medical condition, including my PHI, with the UCB Patient Assistance Program, UCB, and/or their agents, which may administer the Program. This information will be used and shared to determine whether I am eligible for insurance coverage or other reimbursement for the medication(s) for which I am applying, whether I am eligible for the Program, to administer the Program, and to assess the quality of Program services provided by UCB, its vendors and its contractors. I understand that once the Program receives my information, it may be re-disclosed and no longer protected by federal privacy regulations. I understand that if I do not sign this authorization or if I cancel it, I cannot participate in the Program. I understand that I may cancel this Authorization at any time by mailing a written request for such cancellation to my prescribing physician, and the cancellation will not apply to any information already used or disclosed pursuant to this Authorization. I have read this document or have had it explained to me. I understand that I may request a copy of this Authorization once it has been signed. Patient s (or authorized patient representative) Signature: Date: USP-MP.0216-0003(1)