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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
18,000+ 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
www.needymeds.org
NeedyMeds
Find help with the cost of medicine
NeedyMeds.org
P.O. Box 219
Gloucester, MA 01931
Helpline
: 1-800-503-6897
Email: info@needymeds.org
www.needymeds.org
Form from www.needymeds.org
BIN: 020750
RX PCN: NMeds
RX GRP: PDFPDF
ID: NMNA019309901930
This is a drug discount program, not an insurance plan.
Clip the card and save
• Save up to 80% on medications*
• Use at over 65,000 pharmacies
nationwide including all major chains
• Share the card with friends and family
• Use the card as oen as needed
• Free, no fees or registration
• Never expires
• A drug isn’t covered by your insurance
• Your insurance has no drug coverage
• You have a high drug deductible
What if I have insurance?
Anyone can use the card, but it can’t be combined with state or federal insurance.
You can use the card instead of insurance if:
• 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 will receive a discount?
All prescription medications are eligible for savings, including over-the-counter medicines
and medical supplies written as a prescription, as well as human-equivalent pet medications
with a prescription by a veterinarian.
You can also save up to 40% off durable medical equipment, including canes, crutches, splints,
incontinence supplies and more. You can also save on diabetic supplies such as glucose meters,
test strips, lancets and diabetic shoes. Visit www.needymeds.org/dme to learn more.
The card is not valid in combination with 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.
Patient: You may use this card at any of over 65,000
participating pharmacies to save on all prescription medicines.
You cannot use this card with Medicare including part D,
Medicaid, or any other state or federal programs unless you
choose not to use your government-sponsored program. In
addition, you cannot use this card with any health insurance
program, but you can use it in place of your insurance if the
card offers a better price. For questions call 1-888-602-2978
or visit www.drugdiscountcardinfo.com.
NeedyMeds Drug Discount Card
www.needymeds.org
DRUG DISCOUNT CARD
NeedyMeds
NeedyMeds.org
To obtain a plastic drug discount card, send a self-addressed, stamped envelope to:
NeedyMeds Drug Discount Card
PO Box 219
Gloucester, MA 01931
Customer Care
1-888-602-2978
Pharmacist: Administered by Medical Security Company, LLC,
Tucson, AZ.
Pharmacy Help Desk: 1-800-404-1031.
* Average savings of 60%, with potential savings of up to 80% or more (based on 2018 national program savings data).
All prescription medications are eligible for savings.
This is a drug discount program, not an insurance plan. Discounts are available exclusively through
participating pharmacies. The range of the discounts will vary depending on the type of prescription and
the pharmacy chosen. This program does not make payments directly to pharmacies. Users are required to pay
for all prescription purchases. Cannot be used in conjunction with insurance. You may call 1-888-602-2978
with questions or concerns or to obtain further information.
1
Household Income Information (if patient is under the age of 18, please complete information as the legal guardian)Household Income Information (if patient is under the age of 18, please complete information as the legal guardian)
1. Number of people in household: (include yourself, your spouse and any dependents)
2. What is total GROSS ANNUAL household income (including Social Security, Disability, Veterans, Wages, pension
benets, etc.)? $
3. Did the patient/guardian le a Federal Income Tax Return for previous calendar year? YES NO
Please provide us with one of the following items to show total gross annual household income:
• Current paycheck stubs, proof of Social Security Income, 1099 or W-2 forms for all members of household
• Federal Income Tax Return (IRS Form 1040 or 1040EZ) for prior tax year
If the patient has not led a Federal Income Tax Return, visit www.IRS.gov to request a free Verication of Non-Filing.
Click on “Order a Transcript” or call (800) 908-9946. Use IRS Form 4506-T and check box 7 to request verication of
non-ling.
To apply for help in affording your LATUDA
®
(lurasidone HCI) prescription, please see Important Safety
Information on pages 4 and 5 and enclosed full Prescribing Information, and provide information below.
Please mail completed application
to:
Sunovion Support
®
Prescription Assistance Program (“Program”)
PO Box 220285, Charlotte, NC 28222-0285
or fax: (877) 850-0821
Remember to include both your signature and that of your prescribing doctor, proof of income and the patient’s prescription. If you
have any questions or need help lling out this form, please contact us at (877) 850-0819 or visit www.sunovionsupport.com.
Patient Information
Name:
Date of Birth: Phone: ( ) Gender: M F
Mailing Address:
City: State: ZIP:
Is the patient a US resident (includes Puerto Rico)? YES NO
Is the patient 18 years of age or older? YES NO
If Patient is a minor, under the age of 18 years, or has a legal guardian please complete this section:
Parents/Legal Guardian(s) Name:
Phone:
Mailing Address:
City: State: ZIP:
Sunovion Support
®
Prescription Assistance Program © 2020 Sunovion Pharmaceuticals Inc.
PO Box 220285 | Charlotte, NC 28222-0285 | Phone (877) 850-0819 | Fax (877) 850-0821
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2
Patient’s Insurance Information
1. Is the patient enrolled in Medicare/Medicaid? YES NO
2. Does the patient have prescription drug coverage through any other benet program that helps pay for prescription
medicine, such as private insurance or VA or military benets, including Medicare Part D? YES NO
If yes: please describe:
From the Healthcare Professional (to be completed by the doctor who is prescribing the medicine)
*
Healthcare Professional:
HCCE permit # (required in state of FL only)
Site contact: State License #:
Facility Name: Tax ID #:
Phone: ( ) Fax: ( )
Street address:
City: State: Zip:
Prescription Information: Latuda (lurasidone HCl)
Please see Important Safety Information, including Boxed Warning on pages 4 and 5 and enclosed full Prescribing Information.
Dosage: 20mg/day 40mg/day 60mg/day 80mg/day 120mg/day 160mg/day
Day Supply: 30 Days 60 Days 90 days
Method of delivery:
Prescription to be shipped directly to healthcare professional’s address provided on page 3
Patient will pick up prescription at retail pharmacy (will receive 30 day supply per ll only)
Number of Rells (max 11):
If there is a change in prescription or diagnosis of patient, Sunovion Support needs to be notied in writing.
ICD-10 Code
(required information)
F20.0 Paranoid schizophrenia
F20.1 Disorganized schizophrenia
F20.3 Undierentiated schizophrenia
F20.5 Residual schizophrenia
F20.89 Other schizophrenia
F20.9 Schizophrenia, unspecied
F31.30 Bipolar disorder, current episode depressed, mild or moderate severity, unspecied
F31.31 Bipolar disorder, current episode depressed, mild
F31.32 Bipolar disorder, current episode depressed, moderate
F31.4 Bipolar disorder, current episode depressed, severe, without psychotic features
* If Healthcare Provider is not an MD please provide required supporting documentation authorizing prescribing of and receiving of prescription
medication. Please visit the website www. NABP.net if you have questions as to what your state may require for you to receive medication
shipped directly to you. All required documentation must be received to ship medication.
Sunovion Support
®
Prescription Assistance Program © 2020 Sunovion Pharmaceuticals Inc.
PO Box 220285 | Charlotte, NC 28222-0285 | Phone (877) 850-0819 | Fax (877) 850-0821
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3
Your Consent is Required to Process Application for the Sunovion Support Prescription Assistance Program
I acknowledge and agree that the above information is complete and accurate. I attest that I have no prescription
insurance coverage, including Medicaid, Medicare or other public or private program, and I have insucient nancial
resources to pay for the prescribed product. I understand and acknowledge that this assistance is temporary and that
this program may be changed or discontinued at any time without notice.
Patient’s Signature: Date:
If you are unable to sign or are a minor, under the age of 18, a parent or legal guardian must also sign.
Representative’s Name:
Representative’s Signature: Date:
Describe relationship to Applicant:
Healthcare Professional Signature is Required to Process Application for the Sunovion Support Prescription
Assistance Program
My signature below certies that the person named in this form is my patient and medication received from the Program
is only for that patient’s use as indicated by the US Food and Drug Administration, and the information provided, to
my knowledge, is accurate. I understand this Program is only for LATUDA and it will not be oered for sale, trade, or
barter. I agree that I will not submit any claim for reimbursement concerning the Product to Medicaid, Medicare, or any
other third party, or return such Product for credit. I also agree that the Program has the right at any time to contact
my patient, to modify or terminate the Program, and to recall or discontinue Product without notice. To the best of my
knowledge, my patient does not have prescription drug insurance coverage (including Medicaid, Medicare, or other
public or private programs) for the product being requested.
Letter of Afliation: I certify that I (a) am aliated with the entity(ies) and location(s) identied on this application, (b) will
be responsible in all respects for the receipt and accountability of the pharmaceutical products shipped to this entity at
such location, and (c) will immediately notify the Program if either of the foregoing statements is no longer true.
Please indicate afliated shipping address for healthcare professional to whom the medication will be shipped:
Healthcare Professional Name:
Street Address:
City: State: Zip: Phone: ( )
Healthcare Professional Signature: Date:
Sunovion Support
®
Prescription Assistance Program © 2020 Sunovion Pharmaceuticals Inc.
PO Box 220285 | Charlotte, NC 28222-0285 | Phone (877) 850-0819 | Fax (877) 850-0821
California residents, please visit www.sunovion.com/CAprivacynotice for information about the collection and use
of your personal information.
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4
Important Safety Information and indications for LATUDA
INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS; AND SUICIDAL THOUGHTS AND BEHAVIORS
Increased risk of death in elderly people with dementia-related psychosis. Medicines like LATUDA can raise the risk
of death in elderly people who have lost touch with reality (psychosis) due to confusion and memory loss (dementia).
LATUDA is not approved for the treatment of people with dementia-related psychosis.
Antidepressant medicines may increase suicidal thoughts or behaviors in some children, teenagers, and young
adults within the rst few months of treatment and when the dose is changed. Depression and other serious mental
illnesses are the most important causes of suicidal thoughts and actions. Patients on antidepressants and their families
or caregivers should watch for new or worsening depression symptoms, especially sudden changes in mood,
behaviors, thoughts, or feelings. This is very important when an antidepressant medicine is started or when the
dose is changed. Report any change in these symptoms immediately to the doctor.
LATUDA may cause serious side eects, including:
• Stroke (cerebrovascular problems) in elderly people with dementia-related psychosis that can lead to death.
• Neuroleptic malignant syndrome (NMS) is a serious condition that can lead to death. Call your health care provider or go
to the nearest hospital emergency room right away if you have some or all of the following signs and symptoms of NMS: high
fever, increased sweating, sti muscles, confusion, or changes in your breathing, heart rate, and blood pressure
• Uncontrolled body movements (tardive dyskinesia). LATUDA may cause movements that you cannot control in your face,
tongue, or other body parts. Tardive dyskinesia may not go away, even if you stop taking LATUDA. Tardive dyskinesia may
also start after you stop taking LATUDA
• Problems with your metabolism such as:
• High blood sugar (hyperglycemia) and diabetes: Increases in blood sugar can happen in some people who take
LATUDA. Extremely high blood sugar can lead to coma or death. If you have diabetes or risk factors for diabetes (such as
being overweight or a family history of diabetes), your health care provider should check your blood sugar before you start
and during treatment with LATUDA
• Call your health care provider if you have any of these symptoms of high blood sugar (hyperglycemia)
while taking LATUDA: feel very thirsty, need to urinate more than usual, feel very hungry, feel weak or tired, feel
sick to your stomach, feel confused, or your breath smells fruity
• Increased fat levels (cholesterol and triglycerides) in your blood
• Weight gain. You and your health care provider should check your weight regularly during treatment with LATUDA
• Increased prolactin levels in your blood (hyperprolactinemia). Your health care provider may do blood tests to check your
prolactin levels during treatment with LATUDA. Tell your health care provider if you have any of the following signs and symp-
toms of hyperprolactinemia:
• Females: absence of your menstrual cycle or secretion of breast milk when you are not breastfeeding
• Males: problems getting or maintaining an erection (erectile dysfunction) or enlargement of breasts (gynecomastia)
• Low white blood cell count. Your health care provider may do blood tests during the rst few months of treatment with
LATUDA
• Decreased blood pressure (orthostatic hypotension). You may feel lightheaded or faint when you rise too quickly from a
sitting or lying position
• Falls. LATUDA may make you sleepy or dizzy, may cause a decrease in your blood pressure when changing position
(orthostatic hypotension), and can slow your thinking and motor skills, which may lead to falls that can cause fractures or
other injuries
• Seizures (convulsions)
• Problems controlling your body temperature so that you feel too warm. Do not become too hot or dehydrated during
treatment with LATUDA. Do not exercise too much. In hot weather, stay inside in a cool place if possible. Stay out of the sun.
Do not wear too much clothing or heavy clothing. Drink plenty of water
• Mania or hypomania (manic episodes) in people with a history of bipolar disorder. Symptoms may include: greatly increased
energy, severe problems sleeping, racing thoughts, reckless behavior, unusually grand ideas, excessive happiness or
irritability, or talking more or faster than usual
• Diculty swallowing
Sunovion Support
®
Prescription Assistance Program © 2020 Sunovion Pharmaceuticals Inc.
PO Box 220285 | Charlotte, NC 28222-0285 | Phone (877) 850-0819 | Fax (877) 850-0821
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5
Do not drive, operate heavy machinery, or do other dangerous activities until you know how LATUDA aects you. LATUDA may
make you drowsy.
Avoid eating grapefruit or drinking grapefruit juice while you take LATUDA since these can aect the amount of LATUDA in the
blood.
Do not take LATUDA if you are allergic to any of the ingredients in LATUDA or take certain medications called CYP3A4 inhibitors
or inducers. Ask your health care provider if you are not sure if you are taking any of these medications.
Tell your health care provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins,
and herbal supplements. LATUDA and other medicines may aect each other, causing possible serious side eects. LATUDA may
aect the way other medicines work, and other medicines may aect how LATUDA works. Your health care provider can tell you if it
is safe to take LATUDA with your other medicines. Do not start or stop any other medicines during treatment with LATUDA without
talking to your health care provider rst.
Before taking LATUDA, tell your health care provider about all of your medical conditions, including if you:
• have or have had heart problems or stroke
• have or have had low or high blood pressure
• have or have had diabetes or high blood sugar, or have a family history of diabetes or high blood sugar
• have or have had high levels of total cholesterol or triglycerides
• have or have had high prolactin levels
• have or have had low white blood cell count
• have or have had seizures
• have or have had kidney or liver problems
• are pregnant or plan to become pregnant. It is not known if LATUDA will harm your unborn baby. Talk to your health care
provider about the risk to your unborn baby if you take LATUDA during pregnancy
• Tell your health care provider if you become pregnant or think you are pregnant during treatment with LATUDA
• If you become pregnant during treatment with LATUDA, talk to your health care provider about registering with
the National Pregnancy Registry for Atypical Antipsychotics. You can register by calling 1-866-961-2388 or going
to http://womensmentalhealth.org/clinical-and-research-programs/pregnancyregistry/
• are breastfeeding or plan to breastfeed. It is not known if LATUDA passes into your breast milk. Talk to your health care
provider about the best way to feed your baby during treatment with LATUDA
The most common side eects of LATUDA include:
• Adults with schizophrenia: sleepiness or drowsiness; restlessness or feeling like you need to move around (akathisia);
diculty moving, slow movements, or muscle stiness; and nausea
• Adolescents (13 to 17 years) with schizophrenia: sleepiness or drowsiness; nausea; restlessness or feeling like you need
to move around (akathisia); diculty moving, slow movements, muscle stiness, or tremor; runny nose/nasal inammation;
and vomiting
• Adults with bipolar depression: restlessness or feeling like you need to move around (akathisia); diculty moving or slow
movements; and sleepiness or drowsiness
• Children (10 to 17 years) with bipolar depression: nausea; weight gain; and problems sleeping (insomnia)
These are not all the possible side eects of LATUDA. For more information, ask your health care provider or pharmacist.
You are encouraged to report negative side eects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call
1 800 FDA 1088.
INDICATIONS
LATUDA is a prescription medicine used:
• To treat adults and adolescents (13 to 17 years) with schizophrenia
• Alone to treat adults, children and teens (10 to 17 years) with depressive episodes that happen with bipolar I disorder (bipolar
depression)
• With the medicine lithium or valproate to treat adults with depressive episodes that happen with bipolar I disorder (bipolar
depression)
SUNOVION, and are registered trademarks of Sumitomo Dainippon Pharma Co. Ltd.
Sunovion Pharmaceuticals Inc. is a U.S. subsidiary of Sumitomo Dainippon Pharma Co. Ltd. ©2020 Sunovion Pharmaceuticals Inc.
Sunovion Support
®
Prescription Assistance Program © 2019 Sunovion Pharmaceuticals Inc.
PO Box 220285 | Charlotte, NC 28222-0285 | Phone (877) 850-0819 | Fax (877) 850-0821
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6
Authorization and Consent to Share and Disclose Health Information with the
Sunovion Support Prescription Assistance Program (“Program”)
Please read and sign this form so that you or the person for whom you are assisting may be able to participate in the Program.
Please note “I” is dened as the potential Participant.
• I acknowledge and agree that all the information I provide in connection with my application to the Program will be used to
decide if I qualify for the Program.
• By signing below, I verify that the information on my application, including a copy of my proof of income documentation, is
complete and accurate.
• I do not have any other coverage for prescription medications, including Medicaid, Medicare, or any public or private assistance
programs or any other prescription insurance.
• I understand that any changes to my nancial, prescription drug coverage, diagnosis, or insurance information may aect whether I
am able to continue to participate in the Program. I agree to contact the Program to inform them of any changes to my income,
prescription drug coverage, diagnosis, or insurance information.
• I allow my health care provider(s), my pharmacy(ies), and my health plan or insurers, to give medical information relating to my use
or need for product(s) provided under the Program to The Lash Group, Inc. The Lash Group runs the Program on behalf of Sunovion
Pharmaceuticals Inc. My medical information can include spoken or written facts about my health and payment benets. It can include
copies of records from my health care provider, pharmacy, or health plan about my health or health care.
• People who work for The Lash Group and the Program may see my information, but they may use it only to help me get assistance to
receive my Sunovion medication, to determine whether I qualify for the Program, to operate the Program, or as otherwise required or
permitted by law.
• I allow The Lash Group and the Program the right to verify and to evaluate any nancial documentation, insurance information, and
medical records submitted to the Program to determine if I qualify for the Program and to operate the Program.
• I understand that The Lash Group and the Program have the right to contact me directly to conrm receipt of medications [or to obtain
my feedback about the Program] and that the Program can revise, change, or terminate the Program at any time.
• I understand that I may cancel my permission and withdraw from this Program at any time.
• I understand that if I cancel my permission I can tell my health care provider, my pharmacy, and my insurer in writing that I do not want
them to share any more information with The Lash Group and the Program, but it will not change any actions they took before I told them
and it will terminate my participation in the Program.
• This authorization and consent will last for up to 6 months.
• I know that I have a right to see or copy the information my health care providers, my pharmacy, or insurers have given to
The Lash Group and the Program.
• I understand that I am free at any time to switch my health care provider and it will not aect eligibility for nancial assistance.
This Program is oered to me regardless of any health care provider or pharmacy I use.
• I KNOW THAT I MAY REFUSE TO SIGN THIS FORM. My choice about whether to sign this form will not change the way my health
care providers, pharmacies, or insurers treat me. If I refuse to sign this form, I know that this means I will not be eligible to participate
in the Program.
• I understand that signature of a legal guardian or parent is required for all minor applicants and those patients who are unable to sign.
Applicant Signature: Date:
Applicant Name:
If you are unable to sign or are a minor, under the age of 18, a parent or legal guardian must also sign.
Representative’s Name: Date:
Representative’s Signature: Describe relationship to Applicant:
If someone helped you with the application and you want them to answer questions for you, please give us their name and phone number:
Name: Phone: ( )
SUNOVION, and are registered trademarks of Sumitomo Dainippon Pharma Co. Ltd.
Sunovion Pharmaceuticals Inc. is a U.S. subsidiary of Sumitomo Dainippon Pharma Co. Ltd. ©2020 Sunovion Pharmaceuticals Inc.
Sunovion Support
®
Prescription Assistance Program © 2019 Sunovion Pharmaceuticals Inc.
PO Box 220285 | Charlotte, NC 28222-0285 | Phone (877) 850-0819 | Fax (877) 850-0821
If you wish to discontinue receiving faxes from this sender, please make your opt-out request to us by fax at (800) 711-7263, or by
telephone at (888) 394-7377. Please specify the telephone number(s) of the fax machine(s) covered by your request. Failure to
comply with your opt out request within the shortest reasonable time, not to exceed 30 days, is unlawful.
Please remove the following fax number(s) from future faxes
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Completed 5 January 2021

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