fax. FAX completed and signed enrollment form to BMS Access Support at

Transcription

1 Simple Steps t Enrll Physician Cmplete the Services, Treatment, and Site f Care (if applicable) Sectins n page 1 Cmplete the Physician Infrmatin sectin n page 2 Read, sign, and date Physician Certificatin n page 2 Have the patient fill ut the Financial Infrmatin sectin n page 3 if requesting Alternative Cverage r Supprt Research Patient Cmplete the Patient Infrmatin sectin n page 3 If enrllment int the BMS Rheumatlgy IV C-Pay Assistance Prgram is requested, please read the Prgram Terms and Cnditins n page 4 If requesting Alternative Cverage r Supprt Research, cmplete the Financial Infrmatin sectin n page 3 Read, sign, and date Patient Authrizatin and Agreement (PAA) n page 6 (initial page 5) FAX cmpleted and signed enrllment frm t BMS Access Supprt at What t Expect After Enrllment Physician Yur BMS Access Supprt representative will: Prvide benefit review results within 24 hurs (within ne business day upn receipt f a cmpleted enrllment frm) Prvide additinal assistance ptins that may be available, if requested Patient Yur physician s ffice will infrm yu f the results f the benefit review when received If c-pay assistance is requested, yu will receive a letter infrming yu f eligibility if accepted Thank yu fr taking the time t cmplete this enrllment frm. If yu have any questins, please cntact BMS Access Supprt at Bristl-Myers Squibb Cmpany. Access Supprt, the Access Supprt lg, and Orencia are trademarks f Bristl-Myers Squibb Cmpany. MMUS /16

2 Services t be cmpleted by Physician Services Requested (Please chse all services desired.) M Benefit Review, Prir Authrizatin, Appeals Assistance M BMS Rheumatlgy IV C-Pay Assistance Prgram M Specialty Pharmacy Crdinatin (fr subcutaneus patients nly) Preferred Specialty Pharmacy: M Alternative Cverage r Supprt Research (eg, independent charitable fundatin referral) M Site f Care Services (fr IV patients nly) Chse if yu r yur patient needs assistance lcating an alternate site f care. BMS cannt guarantee acceptance by any prgram r fundatin. Treatment t be cmpleted by Physician Medicatin Prescribed M ORENCIA (abatacept) Intravenus (IV) M ORENCIA (abatacept) Subcutaneus* (SC) transitining frm IV M ORENCIA (abatacept) Subcutaneus* (SC) new t therapy M ORENCIA (abatacept) Subcutaneus* (SC) new t therapy with IV lading dse *If prescribing SC methd abve, please indicate ne r bth administratin frms desired: M Prefilled Syringe M Clickject TM Autinjectr Treatment Infrmatin Patient Diagnsis: ICD Cde Descriptin Site f Care Services (IV patients nly) t be cmpleted by Physician (Required if Site f Care Services are requested) Please indicate alternate site preference, if any: M Nn-prescribing MD s Office M Hme infusin/infusin Prvider Cmpany M Hspital Outpatient Facility M Other If alternate site f service is knwn please fill ut belw: Physician r Prvider Name Practice/Facility Name First name Last name Facility Address City State Zip Primary Cntact Name Phne Fax Insurance Prvider # Tax ID # 1 f 6 MMUS /16

3 Physician Infrmatin t be cmpleted by Physician Physician Name First name Last name State License # Physician NPI # Physician Tax ID # State Medicaid # Facility Name Phne Fax Facility Address City State Zip Primary Cntact Name Phne Fax Primary Cntact Address Title Physician Certificatin t be cmpleted by Physician I certify t the fllwing: (1) T the best f my knwledge, the patient and physician infrmatin in this frm is cmplete and accurate; (2) I have the authrity t disclse this patient s infrmatin t BMS and its respective agents and assignees, and I have btained this patient s authrizatin fr the disclsure, if required by HIPAA r ther applicable privacy laws; and (3) I have prescribed the medicatin t this patient based n my prfessinal judgment f medical necessity. I certify, if the patient enrlls in the BMS Access Supprt Rheumatlgy IV C-Pay Assistance Prgram, t the fllwing: I have read and will cmply with the Prgram Terms and Cnditins n page 4 T the best f my knwledge, this patient satisfies the Patient Eligibility requirements, and I will ntify the Prgram immediately if the patient s insurance status changes T the best f my knwledge, participatin in this Prgram is nt incnsistent with any cntract r arrangement with any third-party payer t which this ffice/site will submit a bill r claim fr reimbursement fr the cvered BMS medicatin(s) administered t the patient The bill r claim that this ffice/site will submit t the insurer r patient fr payment fr BMS medicatin(s) will have the BMS medicatin(s) listed separately frm any bill r claim fr drug administratin r any ther items r services prvided t the patient I will nt submit an insurance claim r ther claim fr payment t any third-party payer (private r gvernment) fr the amunt f assistance that my patient receives frm the Prgram If this ffice/site receives payment directly frm the Prgram fr this patient, the ffice/site will nt accept payment frm the patient fr the amunt received frm the Prgram I understand that BMS (1) may verify all infrmatin prvided, and nt allw r suspend participatin if inadequate infrmatin is received; (2) may mdify, limit, r terminate these prgrams, r recall r discntinue medicatins, at any time withut ntice; and (3) is relying n these certificatins. SIGNATURE Date Physician r Licensed Prescriber signature (required n stamps) 2 f 6 MMUS /16

4 Patient Infrmatin t be cmpleted by Patient Persnal Infrmatin Patient name First name Last name M Male M Female Birth date Address City State Zip Hme phne Mbile Insurance Infrmatin D yu have insurance thrugh: M Private / Emplyer-based insurance M VA r military M State assistance prgram fr medicatin M Medicaid (please check all that apply) Medicare M Part A M Part B M Part D M Medicare Advantage M Nne Primary insurance carrier Primary insurance plicy # Phne Grup # Plicy hlder Secndary insurance carrier Secndary insurance plicy # Phne Grup # Plicy hlder State, Veteran, r Other Prescriptin Cverage Prescriptin Plicy # Phne Grup # Plicy hlder Prescriptin drug insurer Card/bin# Phne # If yu chse Medicaid r Veteran status abve, please chse applicable ptins belw. Medicaid Status M Nt Applied M Denied M Applicatin Pending Veteran Status M Yes M N Applied fr VA M Yes M N Financial Infrmatin t be cmpleted by Patient (Required if Alternative Cverage r Supprt Research is requested) Number f peple in yur husehld (Include yurself, yur spuse, and yur dependents) Yearly husehld incme: $ r Mnthly husehld incme: $ Yur applicatin may be subject t audit r request fr additinal dcumentatin. Scial Security # (ptinal) 3 f 6 MMUS /16

5 BMS Access Supprt Rheumatlgy IV C-Pay Assistance Prgram Terms & Cnditins The BMS Rheumatlgy IV C-Pay Assistance Prgram is designed t assist eligible cmmercially insured patients wh have been prescribed a BMS rheumatlgy IV medicatin with ut-f-pcket deductibles, c-pay, r c-insurance requirements. Patient Eligibility: Yu have cmmercial (private) insurance that cvers yur prescribed Bristl-Myers Squibb (BMS) medicatin, but yur insurance des nt cver the full cst; that is, yu have a c-pay bligatin (ut-f-pcket cst) fr yur prescribed medicatin. Yu are nt participating in any state r federal healthcare prgram including Medicaid, Medicare, Medigap, CHAMPUS, TriCare, Veterans Affairs (VA), r Department f Defense (DD), r any state, patient, r pharmaceutical assistance prgram. Patients wh mve frm cmmercial (private) insurance t a state r federal healthcare prgram will n lnger be eligible. If yu purchased yur prescriptin insurance thrugh a Health Exchange (als knwn as a Health Insurance Marketplace r Small Business Optins Prgram [SHOP] Marketplace), yu are currently eligible. Yu live in the United States r Puert Ric. Prgram Benefits: Yu must pay the first $5 f the c-pay fr each dse f a BMS medicatin cvered by this Prgram. This Prgram will cver the remainder f the c-pay, up t a maximum f $10,000 during a calendar year. Patients are respnsible fr any csts that exceed the Prgram s $10,000 maximum. In rder t receive the Prgram benefits, the patient r prvider must submit an Explanatin f Benefits (EOB) frm, r a Remittance Advice (RA). The submitted frm must include the name f the insurer, plan infrmatin, and shw that the BMS medicatin supprted by this Prgram was the medicatin that was given. The frm must be submitted within 180 days f receiving each dse. The Prgram may apply t retractive ut-f-pcket expenses that ccurred within 120 days prir t the date f the enrllment. These benefits are subject t the $5 patient c-pay requirement and the 12-mnth Prgram maximum f $10,000. The Prgram benefits are limited t the c-pay csts fr BMS medicatins cvered by this Prgram that the patient receives as an utpatient. The Prgram will nt cver, and shall nt be applied tward, the cst f any dsing prcedure, any ther healthcare prvider service r supply charges r ther treatment csts, r any csts assciated with a hspital stay. Prgram Timing: The enrllment perid is 1 calendar year. Patients must enrll by December 31, Additinal Terms and Cnditins f Prgram: Patients, pharmacists, and healthcare prviders must nt seek reimbursement frm health insurance r any third party fr any part f the benefit received by the patient thrugh this Prgram. Patients must nt seek reimbursement frm any health savings, flexible spending, r ther healthcare reimbursement accunts fr the amunt f assistance received frm the Prgram. Acceptance f this ffer cnfirms that this ffer is cnsistent with patient s insurance. Patients, pharmacists, and healthcare prviders must reprt the receipt f c-pay assistance benefits as may be required by patient s insurance prvider. This ffer is nt valid with any ther prgram, discunt, r incentive invlving a BMS medicatin eligible fr this Prgram. Only valid in the United States and Puert Ric; this ffer is vid where prhibited by law, taxed, r restricted. The Prgram benefits are nntransferable. N membership fees. This ffer is nt cnditined n any past, present, r future purchase, including additinal dses. The Prgram is Nt Insurance. Bristl-Myers Squibb reserves the right t rescind, revke, r amend this ffer at any time withut ntice. 4 f 6 MMUS /16

6 Patient Authrizatin and Agreement The BMS Access Supprt prgram is a supprt prgram by Bristl-Myers Squibb Cmpany (BMS) that helps patients understand their insurance cverage and financial supprt ptins fr BMS medicatins, such as c-pay and free medicatin assistance. T participate in the BMS Access Supprt prgram, this prgram will need t receive, use, and disclse yur persnal infrmatin. Please read this authrizatin carefully, and cntact BMS at if yu have any questins. Once yu have read and agreed t this frm, fax yur signed cpy t What infrmatin will be used and disclsed? My persnal infrmatin will be disclsed, including: Infrmatin n this applicatin frm My cntact infrmatin and date f birth Scial Security number (which is vluntary) Financial and incme infrmatin Insurance benefit infrmatin Health recrds and infrmatin, including medicatins prescribed t me 2. Wh will disclse, receive, and use the infrmatin? This authrizatin permits my caretakers, which includes my healthcare prviders, pharmacists, health plans, and health insurers wh prvide services t me, as well as ther peple that I say can help me apply, t disclse my persnal infrmatin t BMS and its authrized agents and assignees (its Administratrs ). BMS and its Administratrs may als share my infrmatin with my caretakers and with ther healthcare prviders, pharmacists, health insurers, and charitable rganizatins t determine if I am eligible fr, r enrlled in, anther plan r prgram. 3. What is the purpse fr the use and disclsure? My persnal infrmatin will be used by and shared with the persns and rganizatins described in this authrizatin in rder t: Prcess my applicatin fr the BMS Access Supprt prgram Prvide the BMS Access Supprt prgram services t me, including verifying my insurance benefits, researching insurance cverage ptins, and referring me t ther plans r assistance prgrams that may be able t help me Prvide c-pay assistance t me, if I am eligible Cntact my caretakers and me abut the prgrams and the services that are available Cntact ther healthcare prviders and charitable rganizatins t determine if I am eligible fr, r enrlled in, anther plan r prgram Imprve r develp the prgrams services 4. When will this authrizatin expire? This authrizatin will be effective fr 5 years unless it expires earlier by law r I cancel it in writing. I may cancel this authrizatin by writing t: BMS Access Supprt P.O. Bx Charltte, NC If I cancel this authrizatin fr a prgram, I will n lnger be able t participate in that prgram. That prgram will stp using r disclsing my infrmatin fr the purpses listed in this authrizatin, except as necessary t end my participatin r as required r allwed by law. (cntinued n next page) Patient r Persnal Representative Initials 5 f 6 MMUS /16

7 Patient Authrizatin and Agreement (cnt d) Rheumatlgy Access and Reimbursement Supprt 5. Ntices I understand that nce my health infrmatin has been disclsed, privacy laws may n lnger restrict its use r disclsure. BMS and its Administratrs agree t use and disclse my infrmatin nly fr the purpses described in this authrizatin r as allwed r required by law. I further understand that I may refuse t sign this authrizatin and that if I refuse, my eligibility fr health plan benefits and treatment by my healthcare prviders will nt change, but I will nt have access t the BMS Access Supprt prgram. I have a right t receive a cpy f this authrizatin after I have signed it. 6. Patient certificatins I certify that the persnal infrmatin that I prvide t BMS is true and cmplete. I agree that, at any time during my participatin in BMS Access Supprt, BMS may request additinal dcumentatin t verify my persnal infrmatin. If there is missing infrmatin r I d nt respnd t requests fr additinal dcuments, my participatin may be delayed r I may n lnger be able t participate. If I qualify fr and receive c-pay assistance frm BMS, I agree t cmply with the prgram Terms and Cnditins and I will nt get reimbursed fr the assistance I receive frm anyne else, including frm an insurance prgram, anther charity, r frm a health savings, flexible spending, r ther health reimbursement accunt. I will cntact BMS Access Supprt at if my insurance r treatment changes in any way. I understand that the BMS Access Supprt prgram may be discntinued r the rules fr participatin may change at any time, withut ntice. I have read this authrizatin and agree t its terms: Print Name f Patient r Persnal Representative Descriptin f Persnal Representative s Authrity Preferred Address Initials Signature f Patient r Persnal Representative Date The patient r his/her persnal representative must be prvided with a cpy f bth pages f this frm after it has been signed. 6 f 6 MMUS /16