Fillable Patient Assistance Program (PAP) Application (City of Oakland)

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Patient Assistance Program (PAP) Application (City of Oakland)

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Patient Assistance Program (PAP)
Application
Thank you for your interest in the Salix Patient Assistance Program sponsored by Salix Pharmaceuticals, Inc. This Patient Assistance Program
is designed to provide temporary assistance and access to Salix patients who meet the pre-defined eligibility criteria. Please complete each
section of the application form as indicated below.
In order for us to process the application form, it must be complete and legible. Each block, line, or space must have an entry. If something
does not apply, please write in N/A. Unfortunately, incomplete applications will delay the review process and final determination.
For questions, please contact the Salix Patient Assistance Program at 1-866-282-6563.
Instructions for Prescriber (5 steps) Instructions for Patient (5 steps)
1. Complete the Prescriber Information Section (II) 1. Complete the Patient Information (Section I)
2. Include State License or NPI Number 2. Complete the Financial Information (Section IV) including:
• All sources of household monthly income
• Total gross monthly medical expenses
• Total assets (i.e., cash, bank accounts, money market
or cash holdings). Do not include values of real estate,
cars, or personal belongings.
3. Sign Attestation 3. Attach proof of income (required)
• Last year’s tax return
• IRS Form 4506-T if no tax return was filed
Other acceptable documentation:
• 1040, 1040A, 1040EZ
• W2
• 1099
• Social Security Statements
4. Complete and sign the Application Form (Section II)
AND sign the Prescription section on the form
(Section III) OR fax a new prescription
4. Complete and sign the Application Form (Sections I, IV, and V)
5. Mail or Fax the completed Application Form, Financial Documentation, and Prescription
(see address and fax information below)
MAIL OR FAX COMPLETED FORM, FINANCIAL DOCUMENTATION, AND PRESCRIPTION TO:
SALIX PATIENT ASSISTANCE PROGRAM
PO BOX 66520 • St. Louis, MO 63166-6520
PHONE 1-866-282-6563 • FAX 1-877-738-3694
Special note: New York prescribers must submit the Salix prescription on an original NY State prescription blank. For all other states, if not faxed, the
prescription must be on a state-specific blank if applicable for your state. Faxed prescriptions must be from the prescriber’s office.
MSAL-US-0004 v1
Patient Assistance Program
APPLICATION FORM
PATIENT INFORMATION (SECTION I)
Patient Name
Primary Phone Number Secondary Phone Number
Street Address
Social Security Number or Green Card Number US Resident
o Yes o No
City State Zip Code
Date of Birth
/ /
Gender
o M o F
Shipping Address for Salix o Same as Address Above
Check Number of People in Household (include self)
o 1 o 2 o 3 o 4 o 5 o 6 o 7 o 8+
City State Zip Code Diagnosis Code(s) List any drug allergies
Are you a veteran of the US Armed Forces?
o Yes o No
Have you received disability payments from Social Security for
more than 24 months? o Yes o No
List any other medications you are currently taking
PRESCRIBER INFORMATION (SECTION II)
Prescriber Name NPI Number State License Number
Street Address Office Contact Name
City State Zip Code Phone Number Fax Number
I request that the Salix medication(s) on the enclosed prescription(s) be provided for the below-named patient who has demonstrated a medical need. To the best of my knowledge, my patient does not have
affordable third party coverage for this prescription through, for example, an HMO, Private Insurance, State Pharmacy Program, Medicare, Medicaid, or Veteran’s Assistance.
Prescriber’s Signature
X
Date
PRESCRIPTION INFORMATION (SECTION III)
*** All prescription information below must be completed by Prescriber in order to process prescription ***
Have your prescriber complete the following information or attach an original prescription from your prescriber. If an original prescription is being sent, the directions must read as indicated below.
Valid for Salix products only – Please complete those that apply. Date
o Anusol-HC
®
2.5% (Hydrocortisone Cream, USP) 30 gm tube
Directions: Apply
o QD o BID o TID o QID o PRN as directed
o Proctocort
®
Cream (Hydrocortisone Cream , USP) 1% 1 oz tube
(Note: a maximum of 3 tubes will be provided for a 90 day supply)
Quantity: x 30 gm tube x 1 oz tube
Refills:
o 1 o 2 o 3
o Anusol-HC
®
(Hydrocortisone Acetate Suppository) 25 mg
Directions: Unwrap and insert one suppository rectally
o QD o BID o TID o QID o PRN
Quantity: x 12 ct x 24 ct
Refills:
o 1 o 2 o 3
o Apriso
®
(mesalamine) Extended-release Capsules .375 g
o Colazal
®
(balsalazide disodium) Capsules 750 mg
oCycloset
®
(bromocriptine mesylate tablets) 0.8 mg
o Fulyzaq
®
(crofelemer) 125 mg Delayed-Release Tablets
o Giazo
®
(balsalazide disodium) Tablets 1.1 g
o Relistor
®
(methylnaltrexone bromide) Subcutaneous Injection 12 mg/0.6 mL
o Relistor
®
(methylnaltrexone bromide) Prefiled Syringe 8 mg/7 syringes per tray
o Relistor
®
(methylnaltrexone bromide) Prefiled Syringe 12 mg/7 syringes per tray
oUceris
®
(budesonide) Extended Release Tablets 9 mg
o Xifaxan
®
(rifaximin) 550 mg Tablets
o Other:
Directions:
Quantity: o 90-day supply o 8 weeks supply
Refills:
o 1 o 2 o 3
o MoviPrep
®
(PEG 3350, sodium sulfate, sodium chloride, potassium chloride, sodium ascorbate and
ascorbic acid for oral solution)
Directions:
o Uceris
®
(budesonide) 2 mg rectal foam
Directions: 1 treatment (4 canisters)
Prescriber’s Signature Required Below:
Substitution Permitted Dispense As Written
o o
Original signature required. Stamped signature not allowed.
Special note: New York prescribers must submit the Salix prescription on an original NY State prescription blank. For all other states, if not faxed, the
prescription must be on a state-specific blank if applicable for your state. Faxed prescriptions must be from the prescriber’s office.
Please print clearly. All items must be completed or application will be returned.
MSAL-US-0004 v1
Patient Assistance Program
APPLICATION FORM
FINANCIAL INFORMATION (SECTION IV)
List All Household Sources (Gross Monthly Amounts)
Salary / Wages $ Alimony / Child Support $ Pension / Retirement $
Disability $ Social Security $ Unemployment / Work $
Total Gross Household Monthly Income Total Monthly Medical Expenses
(includes copays, deductibles, and medical expenses)
Total Patient Household Assets
(excludes home and car)
$ $ $
ATTACH PROOF OF INCOME (Do not send original documents)
INSURANCE INFORMATION (SECTION V)
Private Insurance?
o Yes o No
Medicare Part A?
o Yes o No
State Elderly Drug Assistance?
o Yes o No
Insurer Name:
Policy ID #:
Medicare Part B?
o Yes o No
Group ID#:
Insurer Phone #:
Medicare Part C
(Medicare Advantage)?
o Yes o No
Have you received a denial letter for a Low Income
Subsidy application?
If yes, please attach a copy with your application.
o Yes o No
Prescription Drug Coverage?
o Yes o No
Medicare Part D?
o Yes o No
Do you have VA Benefits?
o Yes o No
Medicaid?
o Yes o No
I hereby consent to allow Salix Pharmaceuticals and its affiliates, agents, and contractors, including the dispensing pharmacy (collectively, “Salix”) to use and/or disclose the information in this form and my
dispensing information to any third party engaged to assist Salix in the administration of the Salix Patient Assistance Program (PAP). I understand that this information will be used to determine my eligibility
for participation in the PAP and to administer the program, except as may be required or permitted by applicable law, and that Salix reserves the right at any time for any reason to contact me and to request
additional information. I understand that I am not required to give my consent, and while that will not impact my health care providers’ treatment of me, if I do not, Salix will not be able to provide me with
the same services. By signing below, I verify that the information in this application, including all copies of documentation, is complete and accurate, and that I am authorized to sign this application. I also
verify that I am not currently receiving benefits for this medication from Medicaid, Medicare, or other public or private insurance or assistance program. I acknowledge and agree that I shall not in any way
report or count the value of the product provided to me under this Program as true out-of-pocket spending (TrOOP) under my Medicare Part D prescription drug benefit. I understand that the information used
or disclosed may be subjected to re-disclosure and no longer protected by HIPAA. I understand that Salix and any third party engaged to assist has the right to verify my eligibility, including the right to audit
any information provided. I also agree that I will contact Salix Pharmaceuticals if any of the information regarding my prescription drug coverage or insurance changes. I also understand that Salix has the
right to contact me directly and to confirm receipt of medications and to revise, change, or terminate this program at any time. I understand that I may revoke this consent and withdraw from participation in
the PAP at any time by either calling the PAP or mailing a letter to the PAP. I understand that this form expires in one year or when my eligibility to the program expires. I understand that the parties disclosing
or receiving my data pursuant to this authorization may receive financial remuneration from Salix.
By signing this form, I authorize the Program and Salix Partners as my designated agent on behalf of my patients, to forward a prescription for medication presented herein by fax or other mode of delivery to
a pharmacy selected by the patient and within the Program network.
Patient’s Signature
X
Date
Please print clearly. All items must be completed or application will be returned.
MAIL OR FAX COMPLETED FORM, FINANCIAL DOCUMENTATION, AND PRESCRIPTION TO:
SALIX PATIENT ASSISTANCE PROGRAM
PO BOX 66520 • St. Louis, MO 63166-6520
PHONE 1-866-282-6563
• FAX 1-877-738-3694
MSAL-US-0004 v1
Special note: New York prescribers must submit the Salix prescription on an original NY State prescription blank. For all other states, if not faxed, the
prescription must be on a state-specific blank if applicable for your state. Faxed prescriptions must be from the prescriber’s office.
ANUSOL-HC Suppository and Cream and Proctocort Cream manufactured by Crown Laboratories. AZASAN manufactured by aaiPharma.
FULYZAQ is manufactured for Salix Pharmaceuticals, Inc by Patheon, Inc. and distributed under license from Napo Pharmaceuticals, Inc.
RELISTOR under license by Progenics Pharmaceuticals, Inc.
XIFAXAN 550 mg is licensed by Alfa Wassermann S.p.A. to Salix Pharmaceuticals, Inc.
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Patient Assistance Program (PAP) Application (City of Oakland)

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Completed 20 January 2022

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