NeedyMeds Find help with the cost of medicine Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need. REMEMBER - Send your completed application to address on the form, NOT to NeedyMeds. 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. 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 1-800-503-6897 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 Richard J. Sagall, MD President, NeedyMeds NeedyMeds.org P.O. Box 219 Gloucester, MA 01931 Phone: 978-281-6666 Email: info@needymeds.org
Clip the card and save NeedyMeds NeedyMeds.org DRUG DISCOUNT CARD BIN: 019520 RX PCN: NMEDS RX GRP: PDFPDF ID: NMNA019309901930 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 1-888-602-2978 or visit www.drugdiscountcardinfo.com. 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 1-866-921-7286. 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 01931 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.
Reset Form For assistance please contact: Qutenza Reimbursement Support Services Phone: 1-877-900-6479, Option 3 Hours of operation: M F, 8 AM 7 PM (ET) Reimbursement Support Form and Prescription for Qutenza (capsaicin) 8% patch Patient Information Fax completed form to: 1-877-304-1045 Please attach an enlarged copy of the front and back of the patient s insurance card and/or other insurance information along with the form.) Patient Name (Last) (First) Street Address: (MI) City: Patient s Initial Treatment? State: Zip: Date of Birth: Sex: Male Female Phone (please provide home/cell/work, if available): Yes Anticipated Treatment Date for this referral? No If No, Date of Initial Treatment? Insurance Information Insurance Phone Number: Primary Insurance: Insured and Relationship to Patient: Member ID: Group ID: Copies of Insurance Cards attached Secondary Insurance: Secondary Insurance Phone Number: Secondary Member ID: Yes No Patient has no coverage for prescription drugs Communication with the Patient It is our standard process to call the patient throughout various points of the process. Please check the appropriate box below so Qutenza Reimbursement Support Services (QRSS) staff understands your preferences regarding communication with your patient. Yes - Qutenza Reimbursement Support Case Manager may contact my patient. No - Qutenza Reimbursement Support Case Manager may NOT contact my patient. My office will provide follow up with the patient. Prescriber Information Office/Site/Clinic: Prescriber s Full Name: Office Contact: City: Address: Phone: Fax: DEA Number (Required): NPI Number (Required): State: Zip: E-mail: Patient Diagnosis B02.23 Postherpetic polyneuropathy TAX ID Number (Required): B02.29 Other postherpetic nervous system involvement PTAN # (Required): Other (specify) The above ICD-10-CM codes do not represent an exhaustive list; providers are responsible for selecting the most appropriate diagnosis code(s) for a specific patient. Application Coding QRSS will determine if this patient s plan has established any coding requirements for the Qutenza application procedure. If plan-specific requirements have NOT been established, QRSS will investigate 64999 and E&M/office visit codes. 64999 and E&M office visits codes only Prescription Information Product Name: Other (specify CPT code and descriptor): Order in Number of Kits: Qutenza (capsaicin) 8% patch 1 Patch Kit (carton includes 1 patch and cleansing gel) NDC 10144-0928-01 2 Patch Kit (carton includes 2 patches and cleansing gel) NDC 10144-0929-01 Medical Necessity Statement of Medical Necessity: Qutenza is medically necessary for the above-referenced patient. It is my intention to treat the above-referenced patient with Qutenza therapy, a drug indicated for the management of neuropathic pain associated with postherpetic neuralgia (PHN). It is my opinion that Qutenza therapy is the most appropriate treatment available for the above-referenced patient. I verify that the patient and prescriber information contained in this enrollment form is complete and accurate to the best of my knowledge and that I have prescribed Qutenza based on my professional judgment of medical necessity. Once approved by me, I authorize Averitas Pharma, Inc, or its affiliated companies or subcontractors to forward this prescription electronically, by facsimile, or by mail to a dispensing pharmacy. I also authorize QRSS to obtain reimbursement for Qutenza including, but not limited to, insurance verification and case assessment. I understand that QRSS may need additional information, and I agree to provide it as needed for the purposes of reimbursement. Prescriber s Full Signature: Date: (No Stamps or Initials) Please see Indication and Important Safety Information on page 3. Page 1
Instructions for Completing the Qutenza (capsaicin) 8% patch Reimbursement Support Form Phone: 1-877-900-6479, Option 3 Fax: 1-877-304-1045 Please write legibly and complete all required fields to prevent delays. This instruction sheet may be used for guidance to assist in the completion of the form. 1. Collect Patient Information Insurance information, including enlarged copies of patient s insurance cards: Communication with Patient: 2. Complete Healthcare Provider Information 3. Complete Treatment Information -10 code 4. Sign Statement of Medical Necessity & Authorization to Release Patient Information The authorization allows the Qutenza Reimbursement Support Services (QRSS) to investigate the patient s insurance coverage acting on behalf of the physician. In order for the program to provide benefits investigation and reimbursement services, we must be authorized to use patient information. The requirement may be satisfied by the patient completing a HIPAA Authorization to Disclose Information form or by the HCPs office executing a Business Associate Agreement (BAA) with Premier Source, the administrator of QRSS. The HIPAA Authorization to Disclose Information form and the BAA can be downloaded from the Qutenza website at www.qutenza.com. 5. Fax completed form to: 1-877-304-1045 6. QRSS will fax a benefits investigation document to your office for you to determine next steps. Please see Indication and Important Safety Information on the next page. Page 2
INDICATION Qutenza (capsaicin) 8% patch is indicated for the management of neuropathic pain associated with postherpetic neuralgia (PHN). IMPORTANT SAFETY INFORMATION Only physicians or healthcare professionals under the close supervision of a physician are to administer Qutenza. Contraindications: None. Warnings and Precautions: Do not use on face or scalp. Aerosolization of capsaicin can occur and inhalation may result in coughing or sneezing. If skin not intended to be treated comes into contact with Qutenza, clean area using Cleansing Gel. Patients may experience substantial procedural pain. Prepare to treat pain with local cooling (such as a cold pack) and/or appropriate analgesic medication. Transient increases in blood pressure may occur during and shortly after the Qutenza treatment. Blood pressure changes were associated with treatment-related increases in pain. Monitor blood pressure and provide adequate support for treatment-related pain. Patients with unstable or poorly controlled hypertension or a recent history of cardiovascular or cerebrovascular events may be at an increased risk of adverse cardiovascular effects. Consider these factors prior to initiating Qutenza treatment. If opioids are used to treat pain associated with the application procedure, please note that opioid treatment may affect the patient s ability to perform potentially hazardous activities such as driving or operating heavy machinery. Adverse Reactions: In clinical trials, serious adverse reactions included application-associated pain and application-site erythema, application-site pain, application-site pruritus, or application-site papules, and nausea. These are not all the side effects of Qutenza. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088. Please review the Full Prescribing Information available at http://www.qutenza.com/docs/qutenza_prescribing_information.pdf Page 3