PATIENT ASSISTANCE PROGRAMS ANTICOAGULANTS (sponsored by drug company)

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1 Program Phone #/Fax Dabigatran [Pradaxa ] Boehringer Ingelheim CARES Foundation Patient Assistance Program Boeringher Ingelheim CARES Foundation Those with Part D Eligible? Must have no prescription coverage for needed medication No, must be ineligible At or below 200% of FPL Must be citizen or legal resident Phone: Fax: Doctor's Action Complete section, sign, attach prescription Applicant's Action Complete, sign, attach proof of income and other requested documentation Up to 90 day supply Doctor's office Doctor/doctor's office must contact company Not applicable New application yearly

2 Boehringer Ingelheim CARES Foundation Patient Assistance Program For Medicare Beneficiaries This program provides help in applying for assistance with the cost of this drug. Same information as above program, but patient may have Medicare insurance Rivaroxaban [Xarelto ] Johnson & Johnson Patient Assistance Foundation, Inc. Hospital Access Patient Assistance Program Eligibility Requirements Johnson & Johnson Patient Assistance Foundation Tel: Those with Part D Eligible? Diagnosis/Medical Criteria Must have no prescription coverage for needed medication No Not disclosed Fax: Obtaining Receiving Returning Doctor's Action Call Faxed Mail or fax Complete section, sign

3 Applicant's Action Decision Communicated Decision Timeframe Complete section, sign, attach proof of income Patient and Doctor notified in writing Doctor's office or patient is sent card to be used at pharmacy Automatically sent out New application, new documentation yearly Dalteparin [Fragmin ] Eisai's Fragmin patient assistance program helps with free or discount Fragmin. Get free or discount Fragmin by applying for Eisai's Fragmin patient assistance program (PAP). Rx help is available to those who meet the Fragmin PAP guidelines below. Fragmin prescription assistance is sponsored by Eisai to help low-income and uninsured patients get expensive brand-name Fragmin either for free or at a large discount. The EISAI Assistance Program Phone: EISAI ( ) Fax: Drug Name: Fragmin Manufacturer: Eisai

4 Program Name: Eisai F s (family size of one family size of two): $21,660 - $29,140; for larger family, refer to application for income s How Dispensed: Dr. Office - 30 days supplys Fondaparinux [Arixtra ] Enoxaparin [Lovenox ] Drug Name: Arixtra Manufacturer: GSK Program Name: GSK Bridges to Access s (family size of one family size of two): $27,075 - $36,425; details found on actual application How Dispensed: Pharm card Additional Arixtra PAP Program Guideline Information: There is also a program for patients on Medicare Plan D. The patient must provide proof that he/she has spent $600 or more for prescription medicines since January 1 and provide a copy of the Medicare Plan D ID card. A pharmacy card will be mailed to use at any pharmacy at no cost. Sanofi Patient Connection Program GSK Bridges to Access Phone: PATIENT ( ) Fax: Sanofi Patient Connection Phone: Eligibility Diagnosis/Medical Criteria Must have no prescription insurance, be ineligible for any state and federal programs; another program (same application) allow the patient to have Medicare coverage At or below 250% of FPL Medically appropriate condition Fax:

5 Yes Decision Communicated Decision Timeframe Hospital notified of acceptance or denial Within 48 hours Up to 90 day supply Doctor's office Within 5-7 business days, call for other options Not applicable New application every 3 months