1 PEGASYS (peginterferon alfa-2a) co-pay card program HElPING ElIGIBlE PATIENTS SAvE ON OuT-OF- POCkET COSTS FOR PEGASYS PRESCRIPTIONS INDICATIONS What is PEGASYS? PEGASYS (peginterferon alfa-2a) is a prescription medication that is: used alone or with COPEGUS (ribavirin, USP) to treat adults and children 5 years and older who have chronic (lasting a long time) hepatitis C infection and certain types of liver problems, and have not taken alpha interferon used if you have chronic hepatitis C; you should not take PEGASYS by itself unless you are not able to take COPEGUS used to treat adults with chronic hepatitis B virus who show signs that the virus is damaging the liver It is not known if PEGASYS is safe and will work in children under 5 years of age. IMPORTANT SAFETY INFORMATION Boxed WARNINGS PEGASYS, like other alpha interferons, may cause or worsen fatal or life-threatening problems (like mental, immune system, heart, liver, lung, intestinal and infections). Your doctor should monitor you during regular visits. If you show signs or symptoms of these conditions, your doctor may stop your medication. In many patients, but not all, these conditions get better after they stop taking PEGASYS (see the Medication Guide for more information and Warnings). Ribavirin, including COPEGUS, can cause birth defects and/or death to an unborn baby. Female patients and the female partners of male patients should avoid getting pregnant. Ribavirin is known to cause anemia (low red blood cells), which can make heart disease worse (see the COPEGUS Medication Guide for more information and Warnings). Please see PEGASYS full Prescribing Information and Medication Guide, including Boxed WARNINGS, and pages 6 to 7 for additional Important Safety Information.
2 pegasys (peginterferon alfa-2a) co-pay card program Making therapy more affordable for patients What is the PEGASYS Co-Pay Card Program? You may need financial assistance even if you have health insurance. The PEGASYS Co-Pay Card Program is designed to reduce co-payments for eligible patients who have been prescribed PEGASYS. By reducing out-of-pocket costs, this program helps give you access to the therapy prescribed by your physician. If I am eligible, how much can I save? Can I use this program? To determine eligibility, please answer the following statements: Patient responsibility YES NO The first $25 of your PEGASYS monthly co-pay, plus 20% of the remaining amount of the co-pay. Up to 80% of your PEGASYS monthly co-pay once you have paid the first $25. I have been prescribed PEGASYS to treat chronic hepatitis C or B. I am age 18 years or older. Program pays I do not live in or get treated in Vermont. For example, if your co-pay is $100: $100 - $25 = $75 80% of $75 = $60 So you only pay $40 total for your monthly PEGASYS therapy. I am covered by a (private nongovernment-funded) healthcare program. To answer YES, you must not be covered by Medicare, Medicare Advantage, Medicare Replacement, Medicaid, TRICARE, or government employee plans, and you must not be receiving free medicine from the Genentech Access to Care Foundation or other programs like it. Program limits My insurance co-pay for PEGASYS is more than $25. Per-year maximum: Up to $1,500 or $2,400, depending on your income Per-month maximum: Up to $125 or $200, depending on your income You are eligible if you answered YES to all of the above. What if I am not eligible for this program? If you are worried about paying for PEGASYS and are not eligible for the Co-Pay Card Program, a PEGASYS Access Solutions Specialist can refer you to co-pay assistance foundations* that may help with your co-pay. Call from 9 am to 8 pm ET, Monday through Friday, or visit PEGASYSAccessSolutions.com. Program does not assist with prescriptions filled prior to the co-pay approval date. For patients with an annual household adjusted gross income exceeding 350% of the federal poverty level, the card has an annual limit of $1500 and a monthly limit of $125. This amount (350%) varies according to year, number of family members and state. If you have no insurance, or your health insurance plan denies you coverage for PEGASYS, you can work with your healthcare provider s office to apply to the Genentech Access to Care Foundation for free medicine. *Genentech does not influence or control the operations of these co-pay assistance foundations, but PEGASYS Access Solutions can assist you in navigating the process of seeking co-pay assistance by making an appropriate referral based on your diagnosis and by assisting with the application process. We cannot guarantee co-pay assistance once you have been referred by PEGASYS Access Solutions. The foundations to which we refer patients each have their own criteria for patient eligibility, including financial eligibility. 2 Please see PEGASYS full Prescribing Information and Medication Guide, including Boxed WARNINGS, and pages 6 to 7 for additional Important Safety Information. 3
3 How do I get started? terms and conditions 1. To activate the PEGASYS Co-Pay Card, simply call or visit activatethecard.com/pegasys Use of the PEGASYS Co-Pay Card does not obligate you to use or continue using any specific product or provider. If you have any questions regarding the PEGASYS Co-Pay Card, please call You will be asked to confirm your residency, annual income (for the upper limit of coverage), insurance status, card ID, date of birth, last 4 digits of your social security number, and contact information. Be sure to have your W-2 form available for income verification. 2. Present your card along with your prescription to your pharmacist You only need to show the card the first time you use it. Your co-pay assistance will then be applied automatically each time you refill your prescription for up to 12 months from the date of activation. Patients must not be the recipient of benefits under any federally funded healthcare program (eg, Medicare, Medicaid, and Tricare). No person or entity may seek reimbursement from any third party for any amount provided using the PEGASYS Co-Pay Card Program. Genentech USA, Inc. reserves the right to deny payment under the PEGASYS Co-Pay Card Program to anyone deemed ineligible in accordance with the stated program criteria. Use of this PEGASYS Co-Pay Card must be consistent with all relevant health insurance requirements and payer agreements. Participating patients and pharmacies are obligated to inform third-party (eg, insurer) payers about this card as provided for under the applicable insurance or as otherwise required by contract or law. Limit one card per patient. Please see your PEGASYS Co-Pay Card for additional terms and conditions. You can activate your card 24 hours a day. If you d like to speak with an operator, call from 8 am to 8 pm ET, Monday through Friday. 4 Please see PEGASYS full Prescribing Information and Medication Guide, including Boxed WARNINGS, and pages 6 to 7 for additional Important Safety Information. 5
4 PEGASYS (peginterferon alfa-2a) Co-Pay Card RxBIN: RxPCN: Loyalty RxGRP: ISSUER: (80840) ID: XXXXXXXXX Please see PEGASYS full Prescribing Information, including Medication Guide, for Important Safety Information. ThIS IS not a BENEfIT plan
5 To the Patient: You must present this card to the pharmacist along with your prescription to participate in this program. If you have any questions regarding your eligibility or benefits, or if you wish to discontinue your participation, call the PEGASYS Co-Pay Program at (8:00 am-8:00 pm ET, Monday- Friday). You are not eligible if prescriptions are paid by any state or other federally funded programs, including, but not limited to, Medicare or Medicaid, Medigap, VA, dod, or TriCare, or where prohibited by law. When you use this card, you are certifying that you understand the program rules, regulations, and terms and you will otherwise comply with the terms and conditions above. To the Pharmacist: When you use this card, you are certifying that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other government-funded programs for this prescription. Submit transaction to McKesson Corporation using BIN # If primary coverage exists, input card information as secondary coverage and transmit using the COB segment of the NCPDP transaction. Applicable discounts will be displayed in the transaction response Aacceptance of this card and your submission of claims for the PEGASYS Co-Pay Card Program are subject to the LoyaltyScript program Terms and Conditions posted at Patient is not eligible if prescriptions are paid in part or in full by any state- or federally funded programs, including, but not limited to, Medicare or Medicaid, Medigap, VA, dod, or TriCare and where prohibited by law For questions regarding setup, claim transmission, patient eligibility, or other issues, call the LoyaltyScript for PEGASYS program at (8:00 am-8:00 pm ET, Monday-Friday) This card is void and prohibited by law and cannot be used in or by residents from Massachusetts.
6 Important safety InformatIon for patients Boxed WARNINGS PEGASYS, like other alpha interferons, may cause or worsen fatal or life-threatening problems (like mental, immune system, heart, liver, lung, intestinal and infections). Your doctor should monitor you during regular visits. If you show signs or symptoms of these conditions, your doctor may stop your medication. In many patients, but not all, these conditions get better after they stop taking PEGASYS (see the Medication Guide for more information and Warnings). PEGASYS can cause serious side effects including: blood problems, thyroid problems, blood sugar problems, serious eye problems, serious liver problems, worsening of liver problems including liver failure and death, lung problems, inflammation of your pancreas, inflammation of your intestines, serious allergic reactions and skin reactions, effect on growth in children, and nerve problems. The most common, but less serious, side effects of PEGASYS include: flu-like symptoms, tiredness and weakness, stomach problems, loss of appetite, skin reactions, hair thinning, trouble sleeping. Ribavirin, including COPEGUS, can cause birth defects and/or death to an unborn baby. Female patients and the female partners of male patients should avoid getting pregnant. Ribavirin is known to cause anemia (low red blood cells), which can make heart disease worse (see the COPEGUS Medication Guide for more information and Warnings). Tell your healthcare provider if you have any side effect that bothers you or that does not go away. What is the most important information I should know about PEGASYS? You may report side effects to the FDA at FDA-1088 or You may also report side effects to Genentech at Ribavirin in combination with PEGASYS may cause birth defects or death of your unborn baby PEGASYS therapy may cause you to develop mood or behavioral problems Some people who take PEGASYS alone or in combination with ribavirin may get heart problems These are not all of the side effects of PEGASYS. For more information, ask your healthcare provider or pharmacist. Please see accompanying PEGASYS full Prescribing Information and Medication Guide, including Boxed WARNINGS, for additional Important Safety Information. Stroke or symptoms of a stroke Some people taking PEGASYS develop new or worsening autoimmune problems Some people who take PEGASYS may get an infection PEGASYS alone or in combination with ribavirin can cause serious side effects. Some of these side effects may cause death. Tell your healthcare provider right away if you have any of these symptoms while taking PEGASYS. Do not take PEGASYS if you: have certain other liver problems have certain types of hepatitis caused by your immune system attacking your liver (autoimmune hepatitis) have had a serious allergic reaction to another alpha interferon medicine or to any of the ingredients in PEGASYS Do not take PEGASYS in combination with ribavirin if you: are pregnant, or planning to get pregnant during treatment or during the 6 months after treatment are a male patient with a female sexual partner who is pregnant or plans to become pregnant at any time while you are being treated with ribavirin or during the 6 months after your treatment has ended have certain blood disorders such as thalassemia major or sickle-cell anemia take didanosine (Videx or Videx EC) Do not give PEGASYS to a baby under 1 year of age. PEGASYS contains benzyl alcohol. Before taking PEGASYS, tell your healthcare provider about all your medical conditions or problems, and if you are pregnant or breastfeeding, or plan to become pregnant or breast feed during treatment with PEGASYS. Tell your healthcare provider about all the prescription and nonprescription medicines, vitamins and herbal supplements you take. 6 PEGASYS and COPEGUS are registered trademarks of Hoffmann-La Roche Inc. All other brands for listed products are trademarks or registered trademarks (as indicated) of their respective owners and are not trademarks of Genentech, Inc. or Hoffmann-La Roche Inc. 7
7 UnsUre about your prescription coverage? Call PEGASYS Access Solutions toll-free at Genentech is committed to helping support the needs of patients taking PEGASYS (peginterferon alfa-2a) Offering you a full range of services, PEGASYS Access Solutions connects you to the medicine you need. While every effort is made to provide helpful information, Genentech makes no representations about the eligibility or guarantee of coverage or reimbursement for any particular claim. Genentech cannot guarantee success in obtaining third-party insurance reimbursement. Third-party coverage and payment for medical products and services is complex and affected by numerous factors. It is always a provider s responsibility to determine and submit the appropriate codes, charges, and modifiers for services that are rendered. Providers should contact third party for specific information on their coding, coverage, and payment policies. All coding and claims used by a provider in seeking reimbursement must be accurate, complete, and adequately documented in the applicable patient record. All services must be medically appropriate. This service is available Monday through Friday, 9 am to 8 pm ET. When contacting PEGASYS Access Solutions, please remember to have your personal insurance information, Medicare, Medicaid, and private health insurance cards available. Please see PEGASYS full Prescribing Information and Medication Guide, including Boxed WARNINGS, and pages 6 to 7 for additional Important Safety Information Genentech USA, Inc. All rights reserved. PEG Printed in USA. (08/13)
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