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 Dear Applicant, ARBOR PHARMACEUTICALS PATIENT ASSISTANCE PROGRAM PATIENT ASSISTANCE PROGRAM Thank you for your interest in the Arbor Pharmaceuticals, LLC. Patient Assistance Program (PAP). Enclosed you will find the requested application. It is important that you complete all requested information and sign where indicated. Incomplete or incorrect applications will delay the application process. Please Note: If the prescription changes, a new application must be submitted for approval. PATIENT REQUIREMENTS: Complete all fields in Sections 1.1 & 1.2 on Page 1 of the Application. Complete Certification Sections 3.1 & 3.2 (if applicable) on Page 2 of the Application. Attach a copy of the ANNUAL household income (Federal tax return (1040), social security income (SSA 1099), pensions, interest, retirement, child support, etc.). See income requirements on the next page. Attach a photocopy of your LIS Denial Letter (for Medicare Part D plan applicants only). If you are a Medicare Part D enrollee you must have applied for and been denied the Low Income Subsidy (LIS) from the Social Security Administration. In order to apply for LIS, please contact the SSA at (800) or go to Attach a photocopy of your Medicaid Denial (if applicable). If you have applied for Medicaid in the past and been denied, please attach a copy of Medicaid denial. LICENSED PRACTITIONER REQUIREMENTS: Complete all fields in Sections 2.1 & 2.2 on Page 1 of the Application. Complete Certification Section 4.1 on Page 2 of the Application. Attach a photocopy of the prescription written for medication listed in section 2.2. Note: If the preprinted office address on the prescription does not match the delivery/mailing address provided in Section 2.1 on the Arbor Pharmaceuticals, LLC. PAP Application form, then the licensed practitioner must attach a copy of their letterhead or a business card to verify the delivery/mailing address provided in Section 2.1. MAIL COMPLETED APPLICATION TO: OR FAX TO: Arbor Pharmaceuticals, LLC. (844) Patient Assistance Program PO BOX 6123 LAWRENCEVILLE, NJ APPLICATION PROCESSING: Please allow 4 weeks for application processing and delivery of medication to the licensed practitioner named on the application form. If the application is approved the medication requested will be shipped directly to the licensed practitioner s office for dispensing. Chronic care patients will receive a 3-month supply every 3 months, not to exceed one year. Prescriptions for chronic care patients must be written for one year. A new application will need to be submitted for approval after the 1-year enrollment period. Acute care patients will receive a one-time shipment and must reapply for each subsequent prescription. Please note missing HCP and/or Patient signature on the application will delay processing. Upon approval, the applicant will be notified by mail. If the applicant is denied, the licensed practitioner and the applicant will be notified by mail. If the application is incomplete the applicant will be notified with instructions for completion. If you have questions or need further assistance, please call our Patient Advocacy Center at between 8:30 AM and 7:00 PM EST, Monday through Friday. Sincerely, Arbor Pharmaceuticals, LLC. Patient Assistance Program

4 ARBOR PHARMACEUTICALS PATIENT ASSISTANCE PROGRAM Eligibility is based on the following requirements: ELIGIBILITY REQUIREMENTS You must not be covered by any private, public, or Medicare Part D health insurance and prescription coverage programs. You must be a citizen of the United States. You must be an outpatient currently under the care of a physician FEDERAL POVERTY GUIDELINES Household Income Requirement: Patient must not have a household income that exceeds 300% of the current US Federal Poverty Guideline for Bidil, and 200% for all other products: Household Size 200% of FPL 300% of FPL (Bidil) Persons in Family or Household 48 Contiguous States and D.C. Alaska Hawaii 48 Contiguous States and D.C. Alaska Hawaii 1 $24,280 $30,360 $27,920 $36,420 $45,540 $41,880 2 $32,920 $41,160 $37,860 $49,380 $61,740 $56,790 3 $41,560 $51,960 $47,800 $62,340 $77,940 $71,700 4 $50,200 $62,760 $57,740 $75,300 $94,140 $86,610 5 $58,840 $73,560 $67,680 $88,260 $110,340 $101,520 6 $67,480 $84,360 $77,620 $101,220 $126,540 $116,430 7 $76,120 $95,160 $87,560 $114,180 $142,740 $131,340 8 $84,760 $105,960 $97,500 $127,140 $158,940 $146,250 Note: Household Size of 9+ will be based on the Household Size of 8.

5 ARBOR PHARMACEUTICALS PATIENT ASSISTANCE PROGRAM SECTION 1.1: PATIENT INFORMATION APPLICATION First Name (legal) MI Last Name Gender: (circle one) Phone Number Social Security Number Date of Birth M F Mailing Address Apt Number City State Zip Code Marital Status Address Gross Monthly HOUSEHOLD Income: Number of People in Household (include yourself): By checking this box and signing sections 3.1 and 4.1 below, I attest to the veracity of the claim of zero income. Have you attached a photocopy of your annual household income (Federal tax return (1040), social security income (SSA 1099), pensions, interest, retirement, child support, etc.)? Yes No Do you have prescription coverage/reimbursement at any time during the year? Yes No If yes, please provide your carrier s name & benefits received for the requested medication: SECTION 1.2: MEDICARE/MEDICAID INFORMATION Are you enrolled in Medicare? Yes No Are you enrolled in Medicaid? Yes No Medicare ID#: Are you enrolled in Medicare Part D plan? Yes No *Medicare Part D enrollees: you must have applied for and been denied the Low Income Subsidy (LIS) from the Social Security Administration before submitting this application. In order to apply for LIS, you may contact the Social Security Administration at (800) , or visit Please attach a photocopy of your LIS denial letter to this application. Have you attached a copy of your Medicare Part D LIS Denial Letter? Yes No SECTION 2.1: LICENSED PRACTITIONER INFORMATION (To be completed by the patient s licensed practitioner) First Name (legal) MI Last Name Professional Designation State License Number DEA Number Mailing Address City State Zip Code Delivery Address City State Zip Code Office Contact Name Phone Number Ext. Office Contact Address SECTION 2.2: PRESCRIPTION INFORMATION (To be completed by the patient s licensed practitioner) Medication: Dosage: This medication is being prescribed for Acute Care Chronic Care * Attach a copy of the prescription to this application.* BOTH PATIENT AND LICENSED PRACTITIONER MUST SIGN AND DATE THE CERTIFICATIONS ON PAGE 2 OF THIS APPLICATION.

6 ARBOR PHARMACEUTICALS PATIENT ASSISTANCE PROGRAM SECTION 3.1: PATIENT CERTIFICATION CERTIFICATIONS I certify that I do not have the ability to pay for the medication requested by my licensed practitioner in section 2.2 of this application and all information provided in section 1.1 and 1.2 is correct. I understand that Arbor Pharmaceuticals, LLC. Patient Assistance Program is entitled to request additional verification of any such information at any time, which I agree to provide. I consent that Arbor may contact me for verification of my application status and receipt of the indicated medications. I understand that if approved, I am not eligible to seek reimbursement for any medication requested in section 2.2 of this application from any government program or third party insurer. I understand eligibility under the Arbor Pharmaceuticals, LLC. PAP is subject to Arbor s discretion and that Arbor reserves the right to modify or terminate the PAP at any time. I authorize my physician to provide Protected Health Information ( PHI ) (as such term is defined in the Health Insurance Portability and Accountability Act and regulations there under, HIPAA, as well as other state or federally protected personal information), to Arbor or third parties engaged, as required to assist Arbor in administering the PAP. I authorize Arbor to disclose my PHI to Centers for Medicare and Medicaid Services ( CMS ) for the purpose of verifying my Medicare Part D enrollment status and disclosing my enrollment in Arbor Pharmaceuticals, LLC. PAP with my Medicare Part D plan. I understand that my PHI will consist of my name, address, social security number, income, prescription coverage, prescription for medication, financial documents and insurance records and will be used for purposes of determining my eligibility to participate in the Arbor PAP and to ship appropriate medication(s) as prescribed by my licensed practitioner. I further understand that if my PHI is incomplete or completed PHI does not allow me to participate in Arbor s PAP that I may be notified of such by Arbor. I understand that upon the furnishing of my PHI to Arbor, my PHI may not be subject to all of the protections and safeguards provided by HIPAA or other federal and state privacy laws. This authorization will extend for as long as I participate in the PAP and will thereafter expire. I may revoke this authorization at any time by providing written notice to Arbor at the address set forth above. My revocation will become effective on the date my written notice is received and processed at Arbor Pharmaceuticals, LLC. PAP. Patient or Legal Guardian s ORIGINAL Signature: Date: SECTION 3.2: MEDICARE PART D ENROLLEE CERTIFICATION (if applicable) I understand that if I am approved for Arbor Pharmaceuticals, LLC. PAP, I will receive a three-month supply of medication and that I must reapply to Arbor Pharmaceuticals, LLC. PAP each time I need medication. I understand that if my application continues to meet the guidelines of Arbor Pharmaceuticals, LLC. PAP, I will continue to be approved to receive subsequent three-month supplies of medication up to 12 months for Chronic Care prescriptions and a one-time shipment for Acute Care prescriptions. I will reapply for each subsequent Acute Care request as needed. I agree that I will not seek the requested Arbor medication from my Medicare Part D prescription plan while receiving the medication from Arbor PAP. I understand that I am not eligible to seek reimbursement for any medication dispensed by Arbor from any government program or third party insurer and will not apply any Arbor Pharmaceuticals, LLC. PAP medication towards True Out-Of-Pocket ( TrOOP ) costs. Patient or Legal Guardian s ORIGINAL Signature: Date: SECTION 4.1: LICENSED PRACTITIONER CERTIFICATION My signature certifies that I am a licensed practitioner eligible under state law, my collaborative agreement and formulary, if applicable, to prescribe, receive and dispense the requested medication(s) listed on this application, provided by Arbor Pharmaceuticals, LLC. I further certify all information provided in section 2.1 & 2.2 is correct and agree to submit appropriate verification of such information upon Arbor s reasonable request. I agree that medication(s) provided to me by Arbor pursuant to prescriptions provided by me for the applicant named in 1.1 will be provided by me to such eligible applicant for his or her own use without charge. I will not otherwise use any of such medications or prescribe, provide or dispense all or any portion thereof for the use of any other person. I consent that Arbor may contact the applicant named in section 1.1 for verification of applicant status and receipt of the indicated medication(s). I further consent that Arbor may perform an on-site audit of PAP records related to the applicant named in 1.1 of this application. I understand that I am not eligible to seek reimbursement for any medication dispensed by Arbor Pharmaceuticals, LLC. PAP from any government program or third party insurer and will not apply any Arbor PAP medication towards the applicant s TrOOP. I further understand that I cannot seek payment for an office visit from the applicant or third party insurer when Arbor PAP medication is provided to the applicant. I also understand that eligibility under the PAP is subject to Arbor Pharmaceuticals, LLC. s discretion and that Arbor Pharmaceuticals, LLC. reserves the right to modify or terminate the PAP at any time. Physician s ORIGINAL Signature: Must be Original Signature No stamped Signatures Accepted Date: