Access Support Enrollment Form Complete and fax this form to

Transcription

1 Access Support Enrollment Form Complete and fax this form to PATIENT INFORMATION NAME (First, MI, Last) SEX M F DOB (MM/DD/YYYY) CITY STATE ZIP CODE HOME/CELL PHONE WORK PHONE BEST TIME TO CONTACT Insurance information: No Insurance (Please ensure provider signs Section 4 and patient completes Section 6) PRIMARY INSURANCE CARDHOLDER RELATIONSHIP TO CARDHOLDER EMPLOYER INS. CO. PHONE POLICY# GROUP# SECONDARY INSURANCE CARDHOLDER RELATIONSHIP TO CARDHOLDER EMPLOYER INS. CO. PHONE POLICY# GROUP# PRESCRIPTION DRUG INSURER CARD/BIN# PHONE 2. PRESCRIBER INFORMATION PRESCRIBER NAME (First, Last) SPECIALTY PRACTICE NAME OFFICE CONTACT CITY STATE ZIP CODE PHONE FAX MEDICAID/MEDICARE PROVIDER# TAX ID# STATE LICENSE # UPIN#/NPI# Are you the prescribing specialist? YES NO: IF NO, REFERRING SPECIALIST REFERRING PHYSICIAN SPECIALTY 3. CLINICAL INFORMATION PATIENT DIAGNOSIS ICD CODE: PRIOR MEDICATIONS* (Specify: P-Prior, C-Current, F-Failure) Actemra Cimzia Enbrel Humira Simponi Orencia Kineret Methotrexate Remicade Rituxan Other: Please Specify THERAPY INFORMATON Orencia Intravenous (IV) Orencia SC (transitioning from IV) Orencia Subcutaneous (SC) Injection (new to therapy) Orencia SC (new therapy with IV loading dose) 4. PROVIDER CERTIFICATION I certify that: (1) to the best of my knowledge the information in this form is complete and accurate. (2) I have the authority to disclose this patient s information and have obtained this patient s authorization for the disclosure, if required by HIPAA or other applicable privacy laws. (3) I have prescribed the product based on my professional judgment of medical necessity. If my patient participates in the Co-pay Assistance Program, I certify that: (1) To the best of my knowledge, this patient satisfies the Program s Eligibility criteria and I will immediately notify the Program if I become aware that this patient s insurance has changed. (2) I have read and agree to all of the Terms and Conditions of the Program. (3) To the best of my knowledge, participation in the Program is not inconsistent with any contract or arrangement with any thirdparty payer to which this office/site will submit a bill or claim for reimbursement for Orencia IV that is administered to the patient. (4) This office/site will comply with applicable obligations, if any, to disclose participation in this Program to the applicable payers. (5) The bill or claim that this office/site will submit to the insurer or patient for payment for Orencia IV have it listed separately from any bill or claim for drug administration or any other items or services provided to the patient. (6) I will not submit an insurance claim or other claim for payment to any third-party payer (private or government) for the amount of assistance that my patient receives from the Program. (7) My office/site will not accept payment from the patient for the amount received from the Program. I will ensure payment is made back to the patient if funds have already been received from the patient for their share of the cost of Orencia IV (minus the patient s obligation of $5 per treatment) for any dates of service paid through the Program. I give permission to: BMS and its agents and assignees to contact this patient to help obtain a signed Patient Authorization and Agreement. Note: Patient signature is required for any services. I understand that: (1) BMS reserves the right to modify or terminate these programs, or recall or discontinue medications, at any time without notice; and (2) BMS is relying on the certifications in this form. Prescriber Signature Date 5. ADDITIONAL ACCESS TO CARE SERVICES (Please check the appropriate box for additional Access to Care Services) Comprehensive Coverage Research provides assistance to my patient in the nature of researching alternative methods of coverage of Orencia (abatacept). By checking this box, you will be required to complete Section 6. The BMS Rheumatology IV Co-pay Assistance Program available only for patients with commercial insurance. Please see accompanying eligibility and terms and conditions for additional restrictions. Specialty Pharmacy Services coordination. By checking this box, you will be required to complete Section 7. Site of Care Services. By checking this box, you will be required to complete Section PATIENT FINANCIAL INFORMATION (Required only if Comprehensive Coverage Research is checked above) Social Security Number Household Size Total Yearly Combined Household Income (Before Taxes) Note: Includes salary, pension, Social Security, disability, alimony, child support, interest/dividends, rental property income, etc. Please include proof of income consisting of a copy of Federal tax return, W-2 or copy of recent paystub, copy of Social Security check or awards letter, etc. 7. ACCESS TO CARE: SPECIALTY PHARMACY SERVICES (ORENCIA Subcutaneous Only) Delivery Instructions: Prescriber s Office followed by refills to patient Patient s home Other Address: Name Address City State Zip Code Phone Fax Provider Preferred Specialty Pharmacy 8. ACCESS TO CARE: SITE OF CARE SERVICES (ORENCIA Intravenous Only) Check if you or your patient needs assistance locating an alternate site of care Please indicate alternate site preference, if any: Prescribing MD s Office Non-prescribing MD s office Hospital outpatient Home Infusion/Infusion Provider Company Other If alternate site of service is known please fill out below: PHYSICIAN OR PROVIDER NAME PRACTICE/FACILTY NAME CITY STATE ZIP CODE PHONE FAX CONTACT NAME INSURANCE PROVIDER# TAX ID# * Indicates trademarks are registered trademarks of their respective owners. Actemra (tocilizumab), Cimzia (certolizumab pegol), Enbrel (etanercept), Humira (adalimumab), Kineret (anakinra), Remicade (infliximab), Rituxan (rituximab), Simponi (golimumab). IMMUS /15

2 Access Support Patient Authorization and Agreement Complete and fax both pages of this form to Bristol-Myers Squibb Access Support ( The Program ) is a support program by Bristol-Myers Squibb Company (BMS) that helps patients understand their insurance coverage and financial support options for BMS medications. Please read this Authorization carefully. Fax your signed copy to ) What information will be used and disclosed? My personal information will be disclosed, including: Information on this application form, contact information and date of birth, financial and income information, insurance benefit information, and health records and information, including medications prescribed to me and dates of my infusions. 2) Who will disclose, receive, and use the information? This authorization permits my Caretakers (which includes my healthcare providers, pharmacists, health plans, and health insurers who provide services to me, as well as other people that I say can help me apply) to disclose my personal information to BMS and its authorized agents and assignees ( Administrators ). BMS and its Administrators may also share my information with my Caretakers and with other healthcare providers, pharmacists, health insurers, and charitable organizations to determine if I am eligible for, or enrolled in, another plan or program. 3) What is the purpose for the use and disclosure? My personal information will be used by and shared with the persons and organizations described in this authorization in order to: process my application for the Program; provide the Program services to me, including verifying my insurance benefits, researching insurance coverage options, locating sites of care where I can receive treatment, coordinate prescription information with my specialty pharmacy and referring me to other plans or assistance programs that may be able to help me; provide co-pay assistance to me, if I am eligible; contact my Caretakers and me about the Program and the services that are available; contact other healthcare providers and charitable organizations to determine if I am eligible for, or enrolled in, another plan or program; improve or develop the Program s services. 4) When will this authorization expire? This authorization will be effective for 5 years, unless it expires earlier by law or I cancel it in writing. I may cancel this authorization by writing to BMS Access Support at: P.O. Box Charlotte, NC If I cancel this authorization, I will no longer be able to participate in the Program. The Program will stop using or disclosing my information for the purposes listed in this authorization, except as necessary to end my participation or as required or allowed by law. 5) Notices: I understand that once my health information has been disclosed, privacy laws may no longer restrict its use or disclosure. BMS and its Administrators agree to use and disclose my information only for the purposes described in this authorization or as allowed or required by law. I further understand that I may refuse to sign this authorization and that if I refuse, my eligibility for health plan benefits and treatment by my healthcare providers will not change, but I will not have access to the Program. I have a right to receive a copy of this authorization after I have signed it. Patient Initials

3 6) Patient Certifications: I certify that the personal information that I provide to the Program is true and complete. I agree that, at any time during my participation in the Program, the Program may request additional documentation to verify my personal information. If there is missing information or I do not respond to requests for additional documents, the Program may delay my participation or decide I can no longer participate. If I qualify for, and receive, co-pay assistance from the Program, I agree to comply with the co-pay assistance Eligibility & Terms and Conditions and I will not get reimbursed for the assistance I receive from anyone else, including from an insurance program, another charity, or from a health savings, flexible spending, or other health reimbursement account. I understand that I may not be eligible for co-pay assistance if my prescription drug coverage changes. I will contact BMS Access Support at if my insurance coverage changes in any way. I understand that the Program may be discontinued or the rules for participation may change at any time, without notice. PATIENT SIGNATURE: I have read this authorization, agree to its terms and want to enroll in BMS Access Support. Signature of Patient or Personal Representative Print Name of Patient or Personal Representative Date Description of Personal Representative s Authority

4 TERMS AND CONDITIONS FOR THE ORENCIA (abatacept) CO-PAY ASSISTANCE PROGRAM FOR IV INFUSION Eligibility, Terms, and Conditions Eligibility: You have commercial insurance that covers Bristol-Myers Squibb rheumatology intravenous (IV) medications but your insurance does not cover the full cost; that is, you have a co-pay obligation. You are not participating in any state or federal healthcare program including, without limitation, Medicare, Medicaid, Medigap, CHAMPUS, DOD, VA, TriCare, or any state patient or pharmaceutical assistance program. If you purchased your prescription insurance through a Health Exchange (also known as a Health Insurance Marketplace or Small Business Options Program (SHOP) Marketplace), you are currently eligible. If you move from commercial insurance to a state or federal healthcare program, you will no longer be eligible. You live in the United States or Puerto Rico. Program Benefits: The patient must pay the first $5 of the co-pay for each outpatient dose of the rheumatology IV medication. The Program will cover the remainder of the co-pay for the medication, up to a maximum of $10,000 during a 12-month enrollment period. Patients are responsible for any costs that exceed this $10,000 maximum. Proof required for payment must be a valid Explanation of Benefits (EOB) with product code-specific information. An EOB must be submitted regardless of assigned J-code. EOB must be submitted within 90 days of receiving each treatment to receive co-pay assistance. Benefits may be applied retroactively, subject to the $10,000 maximum, to one treatment that occurred within 45 days prior to the date of enrollment for patients who have had their eligibility confirmed by the Program. Active co-pay cards are for use at the patient s participating healthcare provider office where MasterCard(R) debit cards are accepted. Co-pay assistance can also be provided for the patient through electronic funds transfer, or by check, to the patient s healthcare provider office. The Program benefits are limited to the co-pay costs for outpatient doses of medication only. The Program will not cover, and shall not be applied toward, the cost of any dosing procedure, any other healthcare provider service or supply charges or other treatment costs, or any costs associated with a hospital stay.

5 Program Timing: The enrollment period is 12 months from the date of enrollment. Patients must receive treatment with the medication within 60 days of enrollment in the Program. Additional Terms and Conditions of the Program: Patients, pharmacists, and healthcare providers must not seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this Program. Patients must not seek reimbursement from any health savings, flexible spending, or other healthcare reimbursement accounts for the amount of assistance received from the Program. Acceptance of this offer confirms that this offer is consistent with your insurance and that you will report the value of the co-pay assistance you receive as may be required by your insurance provider. Only valid in the United States and Puerto Rico; this offer is void where restricted or prohibited by law. The Program benefits are not transferable and may not be sold, purchased, traded or counterfeited. Reproductions of the Co-pay Card are void. When the prescription for rheumatology IV medications is filled directly by a pharmacy, the Program card serves as the payment mechanism at the pharmacy only. No membership fees. This offer is not conditioned on any past, present, or future purchase, including additional doses. The Program is not insurance. Bristol-Myers Squibb reserves the right to rescind, revoke or amend this offer at any time without notice.