Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need.

Transcription

1 Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need. Did you know that NeedyMeds has thousands of other free resources? Here s a look at more ways we can help you save money on medicine and healthcare costs. Each one can be found under the Patient Savings tab on our website: Diagnosis-Based Assistance NeedyMeds lists thousands of assistance programs for almost any health condition. If you are going through chemo treatment for cancer, there are programs that can help with wig costs and scalp-cooling products. We also list resources for free diabetes testing supplies, caregiver lodging support, and much more. Free, Low Cost, and Sliding Scale Clinics This popular collection contains information on 16,000+ free, low cost, and sliding scale medical and dental clinics across the U.S. It s a great resource if you need affordable medical treatment and don t know where to go. Coupons, Rebates & More You can use the NeedyMeds website to find nearly 2,000 cost-saving opportunities for both prescription and over-the-counter drugs and medical supplies. Medical Transportation Need help getting to the doctor s office or medical facility? You may be eligible for financial assistance if you meet certain requirements. NeedyMeds also offers information on diagnosis-based camps and retreats, recreational programs, scholarships, government programs, $4 generic drug programs, and more. Finally, I want to tell you about the NeedyMeds Drug Discount Card. Thousands of people use this free, anonymous, and easy-to-use tool to get the best price on their medications. To date, our drug discount card has saved patients over $244,000,000. Check out the next page to learn more. Feel free to call our toll-free helpline if you have any questions. You can reach us at Monday-Friday, 9am-5pm Eastern Time. Thanks for using NeedyMeds! Please let us know if we can do anything else to help you afford the costs of your healthcare. Rich Sagall, MD President, NeedyMeds

2 Clip the card and save NeedyMeds NeedyMeds.org DRUG DISCOUNT CARD BIN: RX PCN: NMEDS RX GRP: PDFPDF ID: NMNA This is a drug discount program, not an insurance plan. NeedyMeds Drug Discount Card Patient: Simply present this card to a participating pharmacy to receive a discount on your prescription. Patients who have Medicare, including Part D, Medicaid or any state or federal prescription insurance can only use this card if they choose not to use their government-sponsored drug plan for their purchase. The card is not valid in combination with those programs. For questions concerning the card, call or visit Pharmacist: Card must be presented to receive program benefits. Clear system of prior cardholder information associated with this universal cardholder ID. For processing questions, call Argus Health Systems at Save up to 80% Use at over 65,000 pharmacies nationwide including all major chains Share the card with friends and family Use the card as often as needed Free, no fees or registration Never expires What if I have insurance? Anyone can use the card, but it can t be combined with insurance. You can use the card instead of insurance if: A drug isn t covered by your insurance Your insurance has no drug coverage You have a high drug deductible You have met a low medicine cap The card offers a better price than your copay You are in the Medicare Part D donut hole What drugs are covered? The card is good for prescription drugs, over-the-counter medicines and medical supplies if written on a prescription blank, and pet prescription medicines purchased at a pharmacy. You ll save on most, but not all, prescriptions. To obtain a plastic drug discount card, send a self-addressed stamped envelope to: NeedyMeds-PAP PO Box 219 Gloucester, MA The card is not valid in combination with other insurance plans, including Medicare, Medicaid or any state or federal prescription insurance. The card can be used only if you decide not to use your government-sponsored drug plan for your purchases.

3 PLEASE COMPLETE AND FAX: / PHONE: MAVYRET ( ) To enroll in MAVYRET Patient Support, complete the patient information and sign the HIPAA Authorization. PATIENT INFORMATION PATIENT TO COMPLETE Patient Name: DOB: Gender: Male Female Other Language: English Spanish Other: Address (No PO Box): City / State / ZIP: Primary Phone #: ALT Phone #: Address: PATIENT CONSENT I would like to receive AbbVie communications about its products, services, or offerings that may be of interest to me. HIPAA Authorization: My signature below certifies that I have read, understood, and agreed to the HIPAA Authorization on page 2. PATIENT SIGNATURE/LEGAL REPRESENTATIVE (Indicate relationship) Date PRESCRIBER INFORMATION PRESCRIBER TO COMPLETE Prescriber Name: NPI #: Specialty: Hepatology Gastro ID Other: State License #: Facility Name: Address: City / State / ZIP: Prescriber Contact Person: Prescriber Phone #: Prescriber Fax #: Prescriber Address: Patient Preferred Pharmacy: Pharmacy Contact & Phone: I certify that the patient and physician information contained in this form is complete and accurate to the best of my knowledge. By signing this form, I certify that I have prescribed MAVYRET to the patient named above and that I have obtained all necessary federal and state authorizations from my patient to allow me to release health information to AbbVie Inc. and the AbbVie Partners (defined on page 2). Prescriber, please print name Please sign Date Please see Important Safety Information, including BOXED WARNING on Hepatitis B Virus reactivation, on page 3. 1

4 DEAR PATIENT, PLEASE RETAIN FOR YOUR RECORDS. MAVYRET PATIENT SUPPORT DESCRIPTION AND PRIVACY NOTICE MAVYRET Patient Support is an AbbVie-sponsored coordination of care program designed to provide personalized treatment support. In order for you to participate, AbbVie, its affiliates, and agents (collectively AbbVie ) will use and disclose your personal information, including your health information, collected on the enrollment form on page 1 and through participation in MAVYRET Patient Support for the following purposes: 1. To enroll you in and provide you with MAVYRET Patient Support and related services, including: reimbursement services, financial assistance (if eligible), nursing services at home and by phone, services to help you and your physicians coordinate the shipment of your medication, and other support services ( MAVYRET Patient Support ). 2. To perform research and data analytics to develop and evaluate products, services, materials, and treatments. 3. To contact you or your alternate contact (if listed) with: (a) informational materials related to your medical condition, relevant patient programs, MAVYRET, and the use of your prescribed AbbVie products; and (b) if you have checked the Patient Consent box on page 1, marketing materials related to AbbVie s products, clinical trial and research opportunities, and other services. AbbVie may combine the information it receives about you with information from other sources. However, AbbVie will not sell or rent any information that can identify you to third parties for their own purposes or otherwise use or disclose any information that can identify you for any purpose not authorized above. If you have questions about this Privacy Notice, want to update your information, terminate your MAVYRET Patient Support enrollment, or opt out of AbbVie marketing, please call or write to AbbVie Customer Service, Department 36M, 1 N. Waukegan Road, North Chicago, IL HIPAA AUTHORIZATION (SIGNATURE ON PAGE 1 OF ENROLLMENT FORM) I authorize my healthcare providers, pharmacies, insurers, and laboratory testing facilities (my Healthcare Companies ) to disclose information about me, my medical condition, treatment, insurance coverage, and payment information in relation to my use of AbbVie products, to AbbVie, its affiliates, and agents/contractors (collectively AbbVie ), to enroll me in and provide me with MAVYRET Patient Support. I understand that information released under this Authorization will no longer be protected by HIPAA. I also understand that if my Healthcare Companies use or disclose my Personal Information for marketing purposes, they may receive financial remuneration. I understand that I am not required to sign this Authorization and that my Healthcare Companies will not condition my treatment, payment, enrollment, or eligibility for benefits on whether I sign this Authorization. This Authorization will expire in 10 years or a shorter period if required by state law, unless I cancel it sooner by calling , or by writing AbbVie Customer Service, Department 36M, 1 N. Waukegan Road, North Chicago, IL I understand that cancelling my Authorization will not affect any use of my information that occurred before my request was processed. 2

5 INDICATION AND IMPORTANT SAFETY INFORMATION 1 INDICATION MAVYRET (glecaprevir and pibrentasvir) tablets are indicated for the treatment of adult patients with chronic hepatitis C virus (HCV) genotype 1, 2, 3, 4, 5, or 6 infection without cirrhosis or with compensated cirrhosis (Child-Pugh A). MAVYRET is also indicated for the treatment of adult patients with HCV genotype 1 infection, who previously have been treated with a regimen containing an HCV NS5A inhibitor or an NS3/4A protease inhibitor (PI), but not both. IMPORTANT SAFETY INFORMATION WARNING: RISK OF HEPATITIS B VIRUS REACTIVATION IN PATIENTS COINFECTED WITH HCV AND HBV: Test all patients for evidence of current or prior hepatitis B virus (HBV) infection before initiating treatment with MAVYRET. HBV reactivation has been reported in HCV/HBV coinfected patients who were undergoing or had completed treatment with HCV direct-acting antivirals and were not receiving HBV antiviral therapy. Some cases have resulted in fulminant hepatitis, hepatic failure, and death. Monitor HCV/HBV coinfected patients for hepatitis flare or HBV reactivation during HCV treatment and post-treatment follow-up. Initiate appropriate patient management for HBV infection as clinically indicated. CONTRAINDICATIONS MAVYRET is contraindicated: In patients with severe hepatic impairment (Child-Pugh C) With the following drugs: atazanavir or rifampin WARNINGS AND PRECAUTIONS Risk of Reduced Therapeutic Effect Due to Concomitant Use of MAVYRET with Carbamazepine, Efavirenz-containing Regimens, or St. John s Wort Carbamazepine, efavirenz, and St. John s Wort may significantly decrease plasma concentrations of glecaprevir and pibrentasvir, leading to reduced therapeutic effect of MAVYRET. The use of these agents with MAVYRET is not recommended. ADVERSE REACTIONS Most common adverse reactions observed with MAVYRET: >10% of subjects: headache and fatigue 5% of subjects: headache, fatigue, and nausea Reference: 1. MAVYRET [package insert]. North Chicago, IL: AbbVie Inc.;