AYUDA ECONÓMICA Y RECURSOS PARA LOS PACIENTES

Transcripción

1 AYUDA ECONÓMICA Y RECURSOS PARA LOS PACIENTES

2 Ayuda y recursos disponibles a su disposición En este folleto, describimos las formas cómo brindamos ayuda y apoyo a los pacientes en su experiencia con BENLYSTA. Aquí encontrará la siguiente información: Verificación del seguro y de los beneficios... 1 Obtenga ayuda para comprender su cobertura de seguro para BENLYSTA. $ Programa de copago de BENLYSTA... 2 Descubra formas para ahorrar. BENLYSTA Connects... 3 Ayuda personal y recursos disponibles para usted. Elija la opción correcta para usted... 4 Aprenda a sacar provecho de todo lo que le ofrecemos.

3 Verificación del seguro y de los beneficios Permítanos ayudarlo a comprender su cobertura de seguro para BENLYSTA (belimumab). Cada póliza de seguro es diferente, y los costos de sus medicamentos dependen de su plan individual. Puede contactarse por teléfono con el competente personal de BENLYSTA Gateway. Nuestro equipo de expertos está preparado para responder sus preguntas acerca de la cobertura de su plan de seguro para BENLYSTA. Descargue el formulario de inscripción para servicios en BENLYSTA.com. (Consulte la información de las páginas 4 y 5). Una vez que recibamos su formulario completo, podremos ayudarlo a determinar su copago, sus gastos máximos de bolsillo y más. Obtenga más información acerca de la cobertura de seguro. Llame a la línea gratuita al BENLYSTA ( ), de lunes a viernes, de 8 a. m. a 8 p. m., hora del Este. 1

4 Programa de copago de BENLYSTA Le gustaría saber si puede disminuir sus gastos de bolsillo para comprar BENLYSTA (belimumab)? Si reúne los requisitos, el programa de copago de BENLYSTA puede cubrir el 100% de sus gastos de bolsillo para adquirir BENLYSTA*. Sí, incluso los pacientes que tienen seguro pueden reunir los requisitos para participar, sin límite de ingresos. Tiene un seguro comercial? Usted puede ser elegible si: Tiene un seguro comercial No tiene seguro No es elegible si: SÍ Tiene un seguro médico o un plan para medicamentos recetados financiado por el gobierno estatal o federal, como Medicare, Medicaid y TRICARE Tiene seguro con un pagador comercial no participante NO Usted puede obtener BENLYSTA gratis a través de nuestro programa de asistencia al paciente (PAP). Los pacientes sin seguro que cumplan con ciertos requisitos financieros pueden calificar. Además, podemos ayudarlo a investigar si existen otros programas que podrían brindarle asistencia. Las personas que no reúnen los requisitos del PAP pueden ser elegibles para el programa de copago de BENLYSTA. Descargue el formulario de inscripción para servicios en el sitio BENLYSTA.com para aplicar al programa de copago de BENLYSTA y al PAP. Complételo con su médico y envíenoslo. * Hasta un total de $11,000 anuales. No cubre el costo de las visitas al consultorio del médico ni de la administración de BENLYSTA. Sujeto a los requisitos de elegibilidad. 2

5 BENLYSTA Connects Estamos aquí para guiar a nuestros pacientes en cada paso. Nuestro compromiso es apoyarlo permanentemente y ayudarlo a trabajar mejor con su equipo de profesionales de la salud. Cuéntenos si comienza a recibir tratamiento con BENLYSTA. Regístrese en BENLYSTA.com y conviértase en miembro de BENLYSTA Connects. Esto es lo que obtendrá: Comunicaciones personalizadas con la información más reciente acerca de BENLYSTA Testimonios personales y consejos prácticos de otros pacientes como usted Herramientas para ayudarlo a fijarse metas y expectativas Una suscripción a Connections, una revista creada para usted Regístrese hoy para recibir apoyo permanente. Visite BENLYSTA.com y conozca BENLYSTA Connects. 3

6 Elija la opción correcta para usted Comience a sacar provecho de todo lo que le ofrecemos. Sea cual sea el tipo de apoyo que esté buscando, pídale ayuda a su médico para completar el anverso del formulario de servicios de BENLYSTA Gateway. A continuación, ponga su firma en el reverso del formulario y envíelo por fax. Uno de nuestros especialistas lo revisará y se pondrá en contacto con usted. 1 Listo para descubrir la cobertura de su plan de seguro para BENLYSTA (belimumab)? Marque la casilla Verificación de beneficios en el anverso del formulario. 2 Quiere saber si es elegible para un copago de $0? Marque la casilla Programa de copago en el anverso del formulario. 3 Le interesa el programa de asistencia al paciente (PAP)? Marque la casilla correspondiente en el anverso del formulario. A continuación, llene la sección PAP en el reverso del formulario. 4 Quiere recibir apoyo permanente de BENLYSTA? Llene la sección correspondiente a apoyo informativo en el reverso del formulario. 4

7 1 2 Services Form for BENLYSTA for subcutaneous use (SC) BENLYSTA for intravenous use (IV) Please complete the form, sign, and FAX back both pages to For assistance with any questions, please call BENLYSTA ( ) REQUIRED: TO BE FILLED OUT BY THE PATIENT PATIENT AUTHORIZATION AND RELEASE TO COLLECT, USE, AND DISCLOSE MEDICAL INFORMATION I understand that the collection, use, and disclosure of my health information are received, but will not apply to the extent that they have already taken action in protected under law. By signing below, I agree to allow my doctors, pharmacies, reliance on this authorization. including my specialty pharmacy(ies), and health insurers (collectively After this authorization is revoked I understand that information provided to GSK Healthcare Providers ), to use and disclose to GlaxoSmithKline and its agents prior to the revocation may be disclosed among GSK and the company or and authorized representatives and any other companies that GlaxoSmithKline companies that help GSK administer the programs in order to maintain records uses (collectively GSK ) to provide the BENLYSTA Gateway the selected of my participation, but it will not be otherwise disclosed or used. services related to my prescribed medication and medical condition for the The patient, or the patient s authorized representative, MUST sign this form in purposes described below. order to receive reimbursement support and assistance from the I understand that my Healthcare Providers will not and may not condition my BENLYSTA Gateway. If an authorized representative signs for the patient, treatment, payment for treatment, eligibility for or enrollment in benefits on please indicate relationship to the patient. whether I sign this Patient Authorization and Release. By signing below, I authorize my Healthcare Providers to disclose my information I understand that certain Healthcare Providers, such as specialty pharmacies, to GSK to do the following: may receive payment from GSK for disclosing my information to GSK for the 1) Request and receive from my doctor, healthcare provider, health insurer, purposes described in this authorization. pharmacy or pharmacist information necessary to investigate and resolve I understand that once information about me is released to GSK based on this my insurance coverage, coding, or reimbursement inquiry, or to review my authorization, federal privacy laws may no longer protect my information and eligibility for patient assistance programs and co-pay assistance; may not prevent GSK from further disclosing my information. However, I understand that GSK has agreed to use or disclose information received only 2) Collect, use, and disclose my information for the purpose of investigating for the purposes described in this authorization or as required by law. and resolving my insurance coverage, coding, or reimbursement inquiry; I understand that this authorization will remain in effect for two (2) years after I 3) Disclose to my treating physician, healthcare provider, pharmacy or sign it or for as long as I participate in the Co-pay or Patient Assistance pharmacist my information when necessary to help to resolve my insurance Program, whichever is longer. I also understand that I have the right to revoke coverage, coding, or reimbursement inquiry. this authorization at any time by mailing a signed written statement of my 4) Contact my insurer, other potential funding sources, and/or patient assistance revocation to PO Box , Charlotte, NC , but that such a programs on my behalf in order to determine if I am eligible for health insurance revocation would end my eligibility to participate in the programs as described. coverage or other funds, and disclose to them my information; and Revoking this authorization will prohibit further disclosures by my Healthcare Providers based on this authorization after the date written revocation is 5) Disclose my information to third parties if required by law. Patient or legal guardian signature: PATIENT SIGN HERE Name (print and indicate relationship to patient): Date PATIENT ASSISTANCE PROGRAM (PAP) UNINSURED PATIENTS Uninsured patients who are prescribed BENLYSTA may be eligible for GSK s Patient Assistance Program (PAP). (Please note that this does not constitute health insurance.) To find if you qualify, please fill in the information below. Annual pretax household income: $ PATIENT COMPLETE Number of family members living in household: PAP applicants are required to submit verification for all sources of household income at time of application, including a copy of one (1) of the following: most recent federal tax return, pay stub, W-2 statement, bank statement, or another source of income verification. This information will only be used to determine eligibility for the PAP. If you do not have one of the above-mentioned sources, please call for more information. 3 PATIENT SERVICES AND SUPPORT Simply check the box below to receive free services and support just for you. You ll also receive ongoing tips, ideas, and the latest news and information about BENLYSTA. (Optional) GlaxoSmithKline (GSK) believes your privacy is important. By providing your name, address, PATIENTCHECK HERE address, and other information, you are giving GSK and companies working with GSK permission to market or advertise to you across multiple channels, e.g. mail, , websites, online advertising, applications, and services, regarding the medical condition(s) in which you have expressed an interest, as well as other healthrelated information from GSK. GSK will not sell or transfer your name, address or address to any other party for their own marketing use. For additional information regarding how GSK handles your information, please see our privacy statement. address: 4 You are encouraged to report negative side effects of prescription drugs to the FDA. Visit or call FDA Please see Important Safety Information for BENLYSTA on pages 3 and GSK group of companies. All rights reserved. Printed in USA R1 July 2017 Page 2 of 4 5

8 Estamos aquí para usted. Obtenga más información hoy mismo. Llame gratis al BENLYSTA ( ). De lunes a viernes, de 8 a. m. a 8 p. m., hora del Este. Las marcas comerciales son propiedad del grupo de empresas de GSK o se le han otorgado bajo licencia GSK group of companies or its licensor. Printed in USA R0_SPAN November 2017