Patient support for eligible and enrolled patients prescribed Tazverik

Once the provider has prescribed Tazverik^® (tazemetostat) tablets, the IPSEN CARES^® Patient Access Specialists are fully dedicated to:

Facilitating eligible patients’ access to their prescribed medications
Providing information and support for the interactions among offices, patients, and insurance companies for Ipsen medications

Actor portrayals unless otherwise noted.

We collect personal information to fulfill your request. Please see our Privacy Policy and our State Supplemental Privacy Policy for more information.

HOW TO ENROLL IN IPSEN CARES PATIENT SUPPORT PROGRAM

IPSEN CARES serves as a central point of contact between patients/caregivers, healthcare providers, insurance companies, and Specialty Pharmacies.

Your Enrollment Form request has been submitted to IPSEN CARES for review. A Patient Access Manager will review your submission and contact both you and your Healthcare Provider within 1 business day. If you have any questions or would like to learn more about IPSEN CARES and its support offerings, please call 866-435-5677, 8:00am to 8:00pm ET Monday through Friday.

Please note: This form will take 10 minutes to complete. There is a requirement for two signatures - first the patient, then the HCP office. If you are applying for PAP, we do have a process for 3rd party verification authorization which would require an additional signature.

Instructions for Patients

Your Healthcare Provider will complete the Steps Outlined in Teal.
You need to complete Steps 2 through 6 Outlined in Orange on the Enrollment Form.
Fill out all sections completely. Missing information could delay your enrollment in IPSEN CARES.

STEP 2: Fill out the Patient Information Section in Step 2.
STEP 3: Fill out the Insurance Information Section in Step 3.
STEP 4: Sign the PATIENT AUTHORIZATION TO USE/DISCLOSE HEALTH INFORMATION in Step 6.

Instructions for Prescribers

Fill out the Prescriber Information Sections in Steps 1, 7-10.
Sign and date the PRESCRIBER/OFFICE MANAGER ATTESTATION at the end of Step 7B.
Step 5 is required for PAP Enrollment Only.

Once a completed Enrollment Form is received, an IPSEN CARES Patient Access Specialist will perform a benefits verification and review the patient’s coverage and out-of-pocket responsibility with both the HCP and the patient typically within 1 business day. To learn more about IPSEN CARES and support offerings, please call 866-435-5677, 8:00 am to 8:00 pm ET Monday through Friday or visit www.ipsencares.com.

STEP 1: Please check all support options

Please check all support options for which the patient is applying:

Quick Start Program

Bridge Supply Program

Patient Assistance Program (PAP)

Copay Assistance Program

• For patients with commercial (private) coverage that covers TAZVERIK® (tazemetostat)

• Only prescribers and approved pharmacy networks can register patients for this program

• Healthcare providers can visit the Tazverik Copay Portal

Next Step

STEP 2: Patient Information

Patient Name

Patient Address

City

State *

Zip

Date of Birth

Home Phone # *

Mobile Phone #

Required if patient is under 18 years of age.

Parent/Legal Guardian Name

Relationship to Patient

Contact Phone #

I give permission to Ipsen to contact me with information via mail, email, phone, or SMS/text message, all of which may include marketing, advertisements, disease state awareness materials and educational material about TAZVERIK and programs that support patients. Automatic dialing may be used. Carrier, text, and data rates may apply. I understand that I am not required to provide this consent as a condition of purchasing any goods or services.

Yes

Next Step

STEP 3: Insurance Information

Is Patient Insured? *

Yes

Primary Insurance Co. *

Insurance Co. Phone # *

Subscriber Policy ID # *

Policy/Employer/Group #

Does patient have secondary insurance? *

Yes

Secondary Insurance Co.

Insurance Co. Phone #

Subscriber Policy ID #

Policy/Employer/Group #

Pharmacy Benefit Manager (PBM) Co.

Phone #

Insurance ID #

Group #

BIN #

PCN #

Is Physician a participating Provider?

Participating

Non-Participating

Uninsured - Patient does not have commercial health insurance and is not eligible for public health insurance, including but not limited to Medicare or Medicaid, or has been denied coverage by their health insurance.

Next Step

STEP 4: Proof Of Income

My estimated annual household income currently is $

Number of people in household

*IPSEN CARES will conduct a soft credit check as part of the process of confirming income and determining eligibility for the Patient Assistance Program (PAP).

Next Step

STEP 5: THIRD PARTY VERIFICATION AUTHORIZATION (required for PAP Enrollment only)

The Patient Assistance Program (PAP) is designed to provide Tazverik at no cost to eligible patients. Patients may be eligible to receive free drug if they are experiencing financial hardship, are uninsured or functionally uninsured, are US residents, and received a valid prescription for an on-label use of Tazverik as supported by information provided in the program application. Eligibility does not guarantee approval for participation in the program. The PAP provides Tazverik product only, and does not cover the cost of previously purchased product or medical services.

THIRD PARTY VERIFICATION AUTHORIZATION (required for PAP Enrollment only)

I understand that I am providing “written instructions” under the Fair Credit Reporting Act (“FCRA”) authorizing the IPSEN CARES Patient Assistance Program (the “Program”), Ipsen Biopharmaceuticals, Inc. (“Ipsen”), and its vendor, on an ongoing basis as needed for the duration of my participation in Program, under the Fair Credit Reporting Act (“FCRA”), to obtain information from my credit profile or other information from a credit reporting agency (including, without limitation, Experian Health), for the purpose of determining financial qualifications and eligibility for programs administered by Ipsen and the Program.

I understand that I am affirmatively agreeing to these terms in order to proceed in this financial screening process. I promise that any information, including financial and insurance information that I provide, are complete and true and, unless I have indicated otherwise, I have no drug insurance coverage, which includes Medicaid, Medicare or any public or private assistance program or any other form of insurance. If my income or health coverage changes, I will call the Program at 1-866-435-5677.

Next Step

STEP 6: PATIENT AUTHORIZATION TO USE/DISCLOSE HEALTH INFORMATION

PATIENT AUTHORIZATION TO USE/DISCLOSE HEALTH INFORMATION: IPSEN CARES® PROGRAM

I authorize my/the patient’s healthcare providers (including those pharmacies that may receive my/the patient’s prescription for Tazverik) to disclose personal health information (“PHI”) about me/the patient, including health information relating to my/the patient’s medical condition, prescription, and insurance coverage, to Ipsen Biopharmaceuticals, Inc., its affiliates, and its agents that have been hired to administer the Ipsen Coverage, Access, Reimbursement & Education Support (IPSEN CARES) program on its behalf (collectively “Ipsen”) in order for Ipsen to: (1) enroll me/the patient in IPSEN CARES Patient Assistance Program (“PAP”) if I/the patient am/is eligible; (2) establish my/the patient’s benefit eligibility for assistance related to potential out-of-pocket costs for Tazverik; (3) send me information about the PAP and other programs that might help me/the patient pay for my/the patient’s Tazverik; (4) provide support services, including patient education and financial assistance for Tazverik; (5) help get Tazverik shipped to my/the patient’s healthcare provider; and (6) facilitate my/the patient’s participation in Tazverik patients programs as I have requested or may request. I agree that, using the contact information I provide, Ipsen may contact me for reasons related to the IPSEN CARES program and support services and may leave messages for me that may disclose that I/the patient am/is on Tazverik therapy. I consent to being contacted by an IPSEN CARES program representative in order for the program to obtain further information or clarification regarding any adverse event I/the patient may experience.

I understand that once my/the patient’s PHI has been disclosed to Ipsen, privacy laws may no longer restrict its use or disclosure; however, Ipsen agrees to protect my/the patient’s information by using and disclosing it only for the purposes described above or as required by law. I understand that my/the patient’s healthcare providers may receive remuneration from Ipsen in exchange for my/the patient’s PHI and/or for any therapy support services provided to me/the patient. I can withdraw this authorization by calling IPSEN CARES at 1-866-435-5677 or mailing a letter requesting such revocation to IPSEN CARES, 2250 Perimeter Park Drive, Suite 300, Morrisville, NC 27560, but it will not change any actions taken before I withdraw authorization. Withdrawal of authorization will end further uses and disclosures of PHI by the parties identified in this form except to the extent those uses and disclosures have been made in reliance upon my authorization. I understand that I may refuse to sign this form and, if I do so, I/the patient will not be able to participate in IPSEN CARES programs, but it will not affect my/the patient’s eligibility to obtain medical treatment, my/the patient’s ability to seek payment for this treatment, or affect my/the patient’s insurance enrollment or eligibility for insurance coverage. This authorization expires three years from the date signed unless a shorter time is required by law or unless I revoke my authorization before that time. I understand that I will receive a copy of the signed authorization.

I promise that any information, including financial and insurance information, that I provide to the PAP is complete and true, and unless I have said something different in this application, I have no insurance coverage for the product, which includes Medicare, Medicaid, or any public or private assistance programs or any other form of insurance. If my income or health coverage changes, I will notify IPSEN CARES at 1-866-435-5677. I understand that Ipsen has the right to contact me directly to confirm receipt of medications. Ipsen may revise, change, or terminate this program at any time.

Next Step

STEP 7: Prescriber Information

Prescriber Name

State License #

Tax ID #

NPI #

Medicaid Provider # (Required if Medicaid Patient)

Office / Institution

Specialty

Street Address

City

State *

Zip

Office Contact and Title

Phone #

Fax #

Preferred Method of Contact

Phone

Fax

Best time to Contact

Morning

Afternoon

Evening

Next Step

STEP 8: Specialty Pharmacy

Select one *

Onco360

Approved On-site Self-dispensing Pharmacy

TAZVERIK will be delivered to the patient’s home unless “Approved On-site Self-dispensing Pharmacy” is selected in this section.

Next Step

STEP 9: Diagnosis

Primary ICD-10 Code

Secondary ICD-10 Code (optional)

Next Step

STEP 10: Prescription And Prescriber/Office Manager Attestation

PRESCRIPTION AND PRESCRIBER/OFFICE MANAGER ATTESTATION
PRESCRIPTION TAZVERIK (tazemetostat) 200 mg tablets

(Attach a separate prescription if this section does not comply with your state’s prescription law.)

Patient Name *

Date of Birth

Please fill in the requested information in the table below.

TAZVERIK Strength	Route of Administration	Frequency	Directions	Quantity	Refills
TAZVERIK Strength	Oral	Frequency	Directions	Quantity	Refills

PRESCRIBER/OFFICE MANAGER ATTESTATION

(The Prescriber must sign if this form is to be used as a prescription to be triaged to a Specialty Pharmacy, to enroll a patient for free goods as part of the Patient Assistance Program (PAP), or to enroll a patient for free goods as part of the Temporary Patient Assistance Program (TPAP).)

By signing below, I certify that a prescription signed by a licensed prescriber is on file for the above therapy and that the patient named on this form has provided the necessary authorization to release the information herein and medical and/or patient information relating to Tazverik therapy to Ipsen and its agents or contractors for the purpose of seeking reimbursement for Tazverik therapy, assisting in initiating or continuing Tazverik therapy, and/or evaluating the patient’s eligibility for Ipsen’s patient support programs administered by IPSEN CARES. I authorize Ipsen to be my agent and to forward the above prescription, by fax or other mode of delivery, to the pharmacy chosen by the patient named on this form. For the state of New York, copies of all prescriptions should be on official New York state prescription forms.

Name

Title

Patient support for eligible and enrolled patients prescribed Tazverik

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Instructions for Patients

Instructions for Prescribers

Welcome to the Ipsen Cares page for Bylvay®(odevixibat). Albireo Assist is now Ipsen Cares.

Ipsen Cares will provide the same comprehensive support to patients prescribed Bylvay.

Welcome to the Ipsen Cares page for Bylvay^®(odevixibat).
Albireo Assist is now Ipsen Cares.