America s Premier Patient Assistance Program
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- Douglas Dominic Moody
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1 888-RxFound ( ) America s Premier Patient Assistance Program RxFoundation simplifies the process to receive free or discounted brand name prescription medications to qualified members. We work with the largest pharmaceutical companies in the United States through their Patient Assistance Programs (PAPs), to ensure a smooth and continuous delivery of your maintenance medications at no or low cost. RxFoundation is a patient advocacy service that helps its members qualify for hundreds of free brand name prescription programs on an on-going basis. For a low monthly fee of $75*, RxFoundation will complete all the paperwork for you the first time and every time you need your medications, with no limit to the number of medications you may need. What are Patient Assistance Programs (PAPs)? QUALIFY FOR FREE OR DISCOUNTED PRESCRIPTION MEDICATIONS Many pharmaceutical companies have PAPs. These PAP programs help individuals maintain their health and well-being by offering free and discount prescription medications for individuals who need assistance. In 2005, PAPs helped over 7 million people by filling more than 36 million prescriptions valued at over $5 billion. Although many people have benefited from PAPs, the process continues to be complicated, timeconsuming and under-utilized. Each pharmaceutical company selects which drugs are available through their programs and how long a person can receive prescription assistance. Since each company sets its own rules and regulations, they each have differing income requirements and coverage limits. The amount of information required varies greatly from company to company and medication to medication, requiring applicants to fill out multiple forms throughout the year. As an RxFoundation member, you will have unlimited access to specialists who coordinate and help with navigating through the prescription assistance process. RxFoundation works together with its members, doctors, insurance, and pharmaceutical companies so that its members receive the medication that they need. *There is a one-time application fee of $ N. Lemon Avenue #334, Walnut, CA RxFOUND ( )
2 Qualifications Guide Through the relationships that RxFoundation has established with multiple pharmaceutical companies and their Patient Assistance Programs, members and their families can receive free medications and much needed prescription drug discounts without having to overcome the many hurdles Example of Monthly Savings with RxFoundation Plan common in the Prescription Assistance Programs as they are currently offered. Mary John Bob While the qualification process varies from manufacturer to manufacturer, there are two basic guidelines that are common across all Patient Assistance Programs. These basic guidelines can be used to determine initial eligibility. Number of Medications Monthly Medication Expense (Out of Pocket) RxFoundation Monthly Expense* $ $ $1, $75.00 $75.00 $75.00 Monthly Savings $ $ $1, Income Qualification Family Size Income Level 1 $20,800 2 $28,000 3 $35,200 4 $42,400 5 $49,600 6 $56,800 7 $64,000 8 $71,200 You and your family may qualify to receive help through Patient Assistance Programs if your income level is at or below what is listed on this chart.* Instructions: Determine your family size by referring to your prior year income taxes. Once you have determined your family size, is your income above or below the corresponding income level? If at or below, you've met the initial income eligibility requirements. 2. Insurance Qualification If you met the income level requirements, you may qualify to participate in Patient Assistance Programs if: a. You do NOT have prescription drug coverage. b. You have exhausted your annual prescription drug coverage limit. c. Your specific medications are not covered (i.e. drug not on your insurance list). Instructions: After confirming that you meet income eligibility requirements, determine whether a., b. or c. above applies. If any apply, you've met the initial coverage eligibility requirement for a Patient Assistance Program and may now submit a membership application to RxFoundation.
3 MEMBERSHIP APPLICATION Page 1 For Office Use Only Referral Name: Referral ID: SECTION 1: Patient Information First Name Middle Initial Last Name Mailing Address (if different) Address Cell Phone Number ( ) - Social Security No. Home Phone Number ( ) - Work Phone Number ( ) - Gender: M F Date of Birth / / Fax Number ( ) - Disabled: Y N - - If "F", is patient currently pregnant? If "Y", has patient been disabled more than Y N two years? Y N U.S. Legal Resident: Y N Veteran: Y N Household Size: Race (optional) Age Employment Status: Employed Self-Employed Unemployed Retired Marital Status: Single Married Divorced Widowed SECTION 2: Monthly Income - Please provide the whole household income per month according to source Salary / Wages $ Social Security Disability $ Rental Income $ Pension/Retirement $ Social Security Retirement $ Unemployment $ Workers Comp. $ Other $ Supplemental S. Income $ Alimony/Child Support $ Veterans Benefits $ TOTAL $ Insurance Information: Indicate below if patient has any type of prescription coverage or medical benefits through any of the following programs. Be prepared to provide additional information on why patient's insurance will not cover their prescribed medications. Write the insurance or program name in the appropriate insurance or program box below. Insurance or Program Rx Benefits Medical Benefits Medicare (Traditional Fee for Service) Insurance or Program Rx Benefits Medical Benefits Medicaid Insurance or Program Rx Benefits Medical Benefits VA Medical Benefits Medicare Supplemental Plan (Medigap) Name: AIDS Drug Assistance Program Other: Name: Medicare Advantage (Medicare HMO) Name: State Children's Health Insurance Program (SCHIP) None - Uninsured Y N Medicare-Approved Drug Discount Card (with Traditional Assistance) Y N Private Insurance Name: Are you allergic to any medications? Y N If yes, list medications: Medicare-Approved Drug Discount Card (without Traditional Assistance) Y N State Elderly Drug Assistance Program (Use additional pages if needed) Personal information submitted within State and Federal confidentiality guidelines and viewed only by RxFoundation.com, LLC.
4 MEMBERSHIP APPLICATION, Page 2 SECTION 3: Prescribing Physician Information Prescribing Physician #1 First Name Middle Initial Last Name Prescribing Physician #2 First Name Middle Initial Last Name Prescribing Physician #3 First Name Middle Initial Last Name Prescribing Physician #4 First Name Middle Initial Last Name Prescribing Physician #5 First Name Middle Initial Last Name Medication Information: Rx Prescription Name Dosage Frequency Prescribing Physician Personal information submitted within State and Federal confidentiality guidelines and viewed only by RxFoundation.com, LLC.
5 MEMBERSHIP APPLICATION, Page 3 PAYMENT AUTHORIZATION FORM Select the appropriate payment method (only one) that should be used to setup your account: CREDIT CARD BANK DRAFT AUTHORIZATION CHECK/MONEY ORDER (3 months billing is required in advance, payable to RxFoundation.com, LLC) Member Information (Required) Member First Name Member Middle Initial Member Last Name Cardholder s Information (Required) Cardholder s First Name (as it appears on card) Cardholder s Middle Initial Cardholder s Last Name Cardholder s Phone # Cardholder s Billing Credit Card Information: (Required if Credit Card payment will be used) Card Type Account Number (note: American Express = 15 digits) Visa MasterCard American Express Discover Verification Code: Exp. Date (mm/yyyy) For Visa, Master Card and Discover the verification code can be found on the back of your credit card. This 3-digit code is usually the last three numbers located in the signature panel. For American Express, you may find your 4-digit card verification number on the front of your credit card above your credit card number on either the right or left side of your credit card. Determine your verification code and enter it here: Bank Draft Authorization: (Required if Bank Draft payment will be used) Account Holder Bank Name State Routing/Transit # (9 Digits) (Required) Account # (Required) Check # (Required) Determining Your Routing Number: To determine your routing number, refer to your personal check. The routing number is ALWAYS 9 digits long and it is enclosed by colons. The location of the routing number and account number on your personal check varies depending on your bank. If you are unsure what the routing number transit number is, your bank can assist you. If you desire, you may also enclose your voided check with this form to avoid any confusion. Payment Authorization (this section must be completed in full) As a convenience, I request and authorize RxFoundation.com, LLC to charge my credit card account or draft my bank account, identified above, for the payment of my $25 initial application fee and the $75 monthly membership premium and/or any applicable fees (returned payment, reinstatement, etc.) I further agree that should this payment be dishonored, whether with or without cause and whether intentionally or inadvertently, RxFoundation.com, LLC will attempt to contact me by phone or mail, but shall be under no liability whatsoever, including any fees imposed by the card issuer, even though such dishonor may ultimately result in forfeiture of coverage. This authorization is to remain in full force and effect until RxFoundation.com, LLC has received written notice of your intention to terminate this agreement. Signature of Credit Card/Bank Draft Account Holder Date Personal information submitted within State and Federal confidentiality guidelines and viewed only by RxFoundation.com, LLC.
6 MEMBERSHIP APPLICATION, Page 4 ADVOCACY CONSENT FORM I, authorize RxFoundation.com, LLC to act on my behalf as my advocate and to: 1. Exchange and receive information to order, obtain and reorder medications on my behalf from companies that manufacture and/or provide medications through patient assistance programs. (initials) 2. Discuss my medical needs with my physician(s) or pharmaceutical companies as needed. (initials) 3. Verify my income through any government agency, employer, company, business and/or organization from which I receive or have received an income. (initials) 4. Provide information to and sign forms on my behalf for obtaining medication from companies that manufacture or provide medications through patient assistance programs. (initials) 5. Arrange for medication to be shipped to my physician's office for pick-up when required. (initials) 6. Receive all correspondence on my behalf from companies that manufacturer and/or provide medication through patient assistance programs regarding the ordering or reordering of my medication. (initials) This authorization is binding for as long as I maintain an active membership with RxFoundation.com, LLC or until I revoke my consent in writing. I also agree that a copy of this form can be accepted as a valid consent to share and receive private health information as it pertains to obtaining name brand prescription medication. I understand that if I do not sign this form, information will not be shared, and I will have to contact each agency, company, or organization individually to give them the information they need. Member First and Last Name (Please Print) Date of Birth: Social Security Number: Address: City: State: Zip: Signature: Date:... If instructed by your Advocate to do so, please have this form Notarized in the space provided below: ACKNOWLEDGEMENT Signed and subscribed to before me, the undersigned authority on the day of, 20. Notary Public Printed Name Personal information submitted within State and Federal confidentiality guidelines and viewed only by RxFoundation.com, LLC.
7 Please keep a copy of the Membership Application for your records and securely send completed Application and any future Pharmaceutical correspondence regarding approvals, ordering or reordering medication to: RxFoundation, LLC 382 N. Lemon Avenue #334 Walnut, CA Phone: 888-RxFound ( ) Fax: info@rxfoundation.com Please visit our website or contact us with any questions. What to expect after submitting your Membership Application: 1. Your assigned Advocate from RxFoundation will be contacting you within 48 hours of receiving the application. 2. Your assigned Advocate will review the application and verify the information with you. 3. Your assigned Advocate will inform you whether your prescription drugs can be provided through the Patient Assistance Program (PAP). 4. Your assigned Advocate will inform you of the requirements for each PAP program. I. Income statement, tax return, or other income verification. II. If you have prescription insurance, a printout from your Pharmacy showing your medication not being covered. 5. A package of information will be mailed to you indicating where signatures are needed. A letter, which your Physician(s) will need to sign, will be included along with a cover letter explaining why this is requested. 6. You will need to collect everything as quickly as possible and mail the completed documents to the address provided in the package. 7. The pharmaceutical companies will notify RxFoundation once your medication(s) have shipped. At that point we will contact you and provide you with the package tracking number(s) for your medication(s).
8 RxFoundation, LLC 382 N. Lemon Avenue #334 Walnut, CA Phone: 888-RxFound ( ) Fax:
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