TOGETHER with TESARO™ Enrollment FormFax completed enrollment form to 1-800-645-9043 1 of 3

capsules 100 mg

Call us at 1-844-2TESARO (1-844-283-7276), Monday-Friday (8 am to 8 pm ET)

Fax us the completed enrollment form at 1-800-645-9043

Email us at information@tesaroprp.com

Visit us at www.TOGETHERwithTESARO.com

❍ Coverage Support (Benefits Investigation, Prior Authorization, and/or Appeals Support)

❍ Financial Assistance (Co-pay Assistance Referrals)

❍ Patient Assistance Program (Patient signature required on the Patient Consent for Patient Assistance Program Form)

❍ Referral to Other Support Services (eg, patient advocacy organizations, peer to peer support, and non-copay support)

Check for services requested:

Prescriber/Facility Information

Prescriber’s Name: ______________________________________________________

Prescriber’s Title: ______________________ Specialty: _____________________

NPI #: _________________________________ DEA #: ________________________

Tax ID #: _______________________________________________________________

Site/Facility Name: ______________________________________________________

Mailing Address: ________________________________________________________

City: __________________________________ State: _________ ZIP: __________

Office Contact’s Name: __________________________________________________

Office Contact’s Phone #: ____________________ Fax #: ___________________

Office Contact’s Email: __________________________________________________

Preferred Method of Contact: ❍ Phone ❍ Email

1

Clinical Information

Primary Diagnosis: ____________________________________________________________ Primary Diagnosis ICD-10 Code: ___________________________________________

Secondary Diagnosis: __________________________________________________________ Secondary Diagnosis ICD-10 Code: _________________________________________

BRCA Test: ❍ Positive ❍ Negative ❍ Results Pending ❍ No Test Recurrent ovarian cancer in complete or partial response to platinum-based chemotherapy: ❍ Yes ❍ No

Known Drug Allergies: ____________________________________________________________________________________________________________________________________

Notes:

3

Please see the instructions guide on page 3 for quick reference on how to fill out this form and enroll your patient in TOGETHER with TESARO.

Patient Information

Patient’s Name: ________________________________________________________

Sex: ❍ Male ❍ Female Date of Birth: _______ / _______ / ______________

Patient’s Address: ______________________________________________________

City: _________________________________ State: ________ ZIP: ___________

Home Phone #: _______________________ Cell Phone #: __________________

Email: _________________________________________________________________

Best Time to Contact:❍ AM (8 am to 10 am) ❍ Day (10 am to 5 pm) ❍ PM (after 5 pm)

Alt. Contact’s Name: ____________________________________________________

Alt. Contact’s Relationship to Patient: _____________________________________

Alt. Contact’s Phone #: __________________________________________________

2

Insurance Information (Check the relevant box) Attach a copy of both sides of the patient’s insurance card.

Primary Insurance Payer: __________________________________________________

Insurance Name: ___________________________________________________________

Phone #: __________________________________________________________________

Policy ID #: ___________________________ Group #: ___________________________

BIN: _________________________________ PCN: _____________________________

Policy Holder’s Name: ______________________________________________________

Policy Holder’s Date of Birth: _______ / _______ / ________________

Policy Holder’s Relationship to Patient: ________________________________________

Prescription Insurance Payer: ______________________________________________

Insurance Name: ___________________________________________________________

Phone #: __________________________________________________________________

Policy ID #: ___________________________ Group #: ___________________________

BIN: _________________________________ PCN: _____________________________

Policy Holder’s Name: ______________________________________________________

Policy Holder’s Date of Birth: _______ / _______ / ________________

Policy Holder’s Relationship to Patient: ________________________________________

4

❍ Medicare ❍ Medicaid ❍ Commercial/Private ❍ Other ❍ Uninsured ❍ Medicare ❍ Medicaid ❍ Commercial/Private ❍ Other ❍ Uninsured

Treatment Target Start Date: _______ / _______ / ________________

Patient’s Name: ____________________________________________________________________________ Patient’s Date of Birth: _____ /_____ /_______

Call us at 1-844-2TESARO (1-844-283-7276), Monday-Friday (8 am to 8 pm ET)

Fax us the completed enrollment form at 1-800-645-9043

Email us at information@tesaroprp.com

Visit us at www.TOGETHERwithTESARO.com

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capsules 100 mg

TOGETHER with TESARO™ Enrollment FormFax completed enrollment form to 1-800-645-9043

TESARO, Inc., and its contractors and agents (together “TESARO”), will use the information you provide to administer and improve TOGETHER with TESARO (the “Program”).

By signing below, you represent, covenant, and certify as follows: (i) My patient has provided all required written authorization(s) as required by HIPAA 164.508 and other federal or state laws to release to TESARO and the Program all patient information needed for this application, including without limitation financial and personally identifiable information in order to (1) conduct coverage support services, and (2) determine eligibility and enroll patient for financial assistance; (ii) all of the information provided in this application is complete and accurate; (iii) ZEJULA was prescribed based on my medical judgment or the medical judgment of another healthcare professional in my office; (iv) I understand and have explained to my patient that TESARO may modify or terminate the Program at any time without notice and that completion of this application does not guarantee enrollment in any particular part of the Program; (v) I have discussed with the patient and the patient has agreed and acknowledged that any medications supplied by TESARO under the Program are for use of the named patient only and shall not be sold, traded, bartered, transferred, returned for credit, submitted to any third-party payer (private or government) for reimbursement, or counted toward the patient’s Medicare Part D out-of-pocket costs; (vi) I have not received nor will I seek or accept payment from my patient for any co-insurance amount paid for by the Program; (vii) I understand that I am under no obligation to prescribe any TESARO drug and I have not received and will not receive any benefit from TESARO for prescribing a TESARO drug; and (viii) if I become aware of any errors in the information provided, I will promptly notify TESARO of those errors.

Healthcare Professional’s Name (Please print): ____________________________________________________________________________________________________________

Healthcare Professional’s Signature (No stamps please): ________________________________________________________________________ Date: _____/_____/________

REQUIRED: Healthcare Professional Policy and Consent8

Preferred Specialty Pharmacy (Select one) Preferred Specialty Pharmacy selection will be honored if permitted by patient’s insurance plan.

❍ No preference ❍ US Bioservices ❍ Diplomat Pharmacy, Inc. ❍ Biologics, Inc. ❍ In-office dispensing site

5

Prescription Information (Commercial Rx)

Patient’s Name: __________________________________________________________________________________ Patient’s Date of Birth: _______ / _______ / ________________

Rx for ZEJULA® (niraparib) Quantity: ________ Refills: __ Treatment Target Start Date: _______ / _______ / ________________

Directions for Use: Take _______ (100-mg) capsules by mouth, with or without food, once daily, at the same time each day (preferably in the evening).

With signature, I authorize TESARO, Inc. and the specialty pharmacy to dispense ZEJULA directly to the patient.

Prescriber’s Name (Please print): _________________________________________________________________________________________________________________________

Prescriber’s Signature (No stamps please): ________________________________________________________________________ Date: _______ / _______ / ________________

Please attach a separate prescription if this section does not comply with your state’s prescription law. Prescriptions from New York must be issued electronically.

The prescribed quantity of ZEJULA will be shipped to the address indicated in Section 6 above.

Other Directions:

7

Preferred Shipping Location (Check one if shipping is needed)

❍ Patient’s Address (address from Section 2) ❍ Other Address (eg, provider office, infusion center):

Facility Name: _________________________________ Phone #: _________________________

Recipient Name: ___________________________________________________________________

Street: ____________________________________________________________________________

City: _____________________________________________State: __________ ZIP: ____________

6

Prescription Information This section is for commercial prescriptions only. If seeking support from the Patient Assistance Program (PAP), you must include a prescription and have your patient complete and sign the Patient Consent for Patient Assistance Program Form.

– Benefits Investigation

– Prior Authorization Facilitation and Appeals Support

– Quick Start and Bridge Programs

– Commercial Co-pay Assistance Program

– Referrals to Patient Advocacy Organizations

Suite of Solutions: – Referrals to Independent Co-pay Foundations

– Patient Assistance Program (PAP)

TESARO, Inc. | 1000 Winter Street | Waltham, MA 02451TESARO, ZEJULA, TOGETHER with TESARO, and the logo designs presented in this material are trademarks or registered trademarks of TESARO, Inc. © 2018 TESARO, Inc. All rights reserved. PP-ZEJ-US-0043 02/18

Call us at 1-844-2TESARO (1-844-283-7276), Monday-Friday (8 am to 8 pm ET)

Fax us the completed enrollment form at 1-800-645-9043 Visit us at www.TOGETHERwithTESARO.com

Email us at information@tesaroprp.com

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capsules 100 mg

TOGETHER with TESARO™ Enrollment FormFax completed enrollment form to 1-800-645-9043

Sections 1 and 2: Patient information in Section 1 must be confirmed by the patient and should match information on the TOGETHER with TESARO™ Enrollment Form. Prescriber information should be entered in Section 2.

Section 3: Should only be completed to determine the patient’s eligibility for financial assistance or enrollment into the Patient Assistance Program (PAP). If seeking TESARO’s PAP, it is important to attach a prescription when you fax this form.

Section 4: Patient signature is required.

Instructions:Complete the first 2 pages of this form.

Have your patient complete the Patient Consent for Patient Assistance Program Form

Fax completed enrollment form to TOGETHER with TESARO. Fax #: 1-800-645-9043

Healthcare Professional to sign and date Section 8 on page 2.

Patient to sign and date the Patient Consent for Patient Assistance Program Form

Select services requested to specify the needs of your patient.

Sections 1 and 2: Prescriber and Patient contact information is required in this section. Be sure to include NPI and DEA numbers to help facilitate the Benefits Investigation.

Section 3: Clinical information requested is very important and often requested when verifying benefits. Diagnosis and appropriate ICD-10 code are required fields. Including clinic notes and/or supporting evidence of BRCA testing with this fax is optional.

Section 4: Be sure to fill out the patient’s insurance information. In addition, a copy of both sides of the patient’s insurance cards can be included at your discretion.

Section 5: Select your preferred specialty pharmacy. If your preferred specialty pharmacy is not in TESARO’s limited distribution network or honored by the patient’s insurance plan, the benefits investigation will inform you of the approved specialty pharmacy options available for your patient.

Section 6: ZEJULA will be delivered to the patient’s home unless otherwise requested in this section.

Section 7: This section can serve as the prescription for ZEJULA for commercial patients. Be sure to attach a separate prescription if this section does not comply with your state’s prescription law. Prescriptions from New York must be issued electronically.

Section 8: Requires a healthcare professional’s signature, either that of a prescriber or a legal representative from the office. A healthcare professional’s signature is required to attest to the review of the policy and consent.

TOGETHER with TESARO™ Enrollment Form

Patient Consent for Patient Assistance Program Form