TOGETHER with TESARO Enrollment Form · PDF file · 2017-11-20Call us at 1-844-2TESARO (1-844-283-7276), Monday-Friday (8 am to 8 pm ET) Fax us the completed enrollment form at

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 [email protected]

Visit us at www.TOGETHERwithTESARO.com

Please see the instructions guide on page 4 for quick reference on how to fill out this form and enroll your patient in TOGETHER with TESARO.

TOGETHER with TESARO™ Enrollment Form

Fax completed enrollment form to 1-800-645-9043 1 of 4

Patient Information

Patient’s Name: ________________________________________________________

Sex: Female Male Date of Birth: _____/____/_______

Patient’s Address: ______________________________________________________

City: _________________________________ State: _________ ZIP: ____________

Home Phone #: ________________________ Cell Phone #: ___________________

Email: _________________________________________________________________

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

Alt. Contact Name:______________________________________________________

Alt. Contact Relationship: ________________________________________________

Alt. Contact Phone #: ___________________________________________________

Insurance Information (Check the relevant box)

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 and Notes:

Attach a copy of both sides of the patient’s insurance card.

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

Attach a copy of both sides of the patient’s insurance card.

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

Financial Assistance (Co-pay Assistance Referrals or Patient Assistance Program)

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

Check for services requested:

Primary Insurance Payer: ________________________________________________

Primary Insurance Plan: __________________________________________________

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: ____________________________________________

Prescription Insurance Plan: _______________________________________________

Phone #: _________________________________________________________________

Policy ID #: ___________________________ Group #: _________________________

BIN: __________________________________ PCN: ___________________________

Policy Holder’s Name: _____________________________________________________

Policy Holder’s Date of Birth: _____/____/_________

Policy Holder’s Relationship to Patient: ______________________________________

Medicare Medicaid Commercial/Private Other Uninsured

4 Attach a copy of both sides of the patient’s insurance card.

Medicare Medicaid Commercial/Private Other Uninsured

1 2

3 Need-by Date: ____/____/________






Prescription Information Please attach or complete both prescriptions below if you are seeking a commercial or Quick Start Program Rx for your patient. The Quick Start Program is optional and may be pursued for eligible patients who are experiencing payer-related delays in coverage determination. These patients will be provided a free 15-day supply of ZEJULA. Terms and conditions apply.*

Preferred Shipping Location (Check one for shipping)

Patient’s Address (address from Section 2)

Preferred Specialty Pharmacy (Select one)

Prescription Information (Commercial Rx)

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

Rx for Zejula™ (niraparib) Quantity: ________ Refills: ________ Need-by 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.

Prescription Information (Quick Start Program Rx)

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

Quick Start Program Rx for Zejula™ (niraparib) Quantity: 15-day supply Refills†: _______ Need-by 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).

Other Directions:

With signature, I authorize TESARO, Inc. and the specialty pharmacy to dispense ZEJULA directly to the patient as part of the Quick Start Program.

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.

* Terms and conditions: The Quick Start Program helps eligible patients obtain ZEJULA at no cost for a limited time. To be eligible for the program, a patient must: (1) have a diagnosis consistent with the product package insert; (2) have a prescription for ZEJULA from their prescribing physician; (3) have insurance; and (4) be experiencing an insurance coverage delay of 5 business days or more.

†Maximum of 5 refills pending resolution of related coverage delay.

Upon receipt of a completed application, the healthcare professional and patient will be notified of program eligibility. If patient is approved for this program, the prescribed quantity of ZEJULA will be shipped to the address indicated in Section 6 at the top of this page.

Other Directions:

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Other Address

Facility Name: _________________________________________ Phone #: ____________________________________________________

Recipient Name: _____________________________________________________________________________________________________

Street: _______________________________________________________________________________________________________________

City: __________________________________________________________________ State: __________________ ZIP: ________________

6

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

Biologics, Inc. Diplomat Pharmacy, Inc. US Bioservices In-office dispensing site



5

REQUIRED: Healthcare Professional Policy and Consent

Financial Assistance This section should only be completed to determine patient’s eligibility for financial assistance or enrollment into the

Patient Assistance Program (PAP). If seeking PAP, please include a prescription with this application.

Patient Financial Information (Required for financial assistance)

Annual Gross Household Income: $ __________________________________________________________________ # of Household Members (Including patient): ______________

9

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 Name (Please print): ______________________________________________________________________________________________________________

Healthcare Professional Signature (No Stamps Please): _________________________________________________________________________ Date: _____/____/_________

Please share a copy of this application with your patient for their records.








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TESARO, Inc. | 1000 Winter Street, Suite 3300 | Waltham, MA 02451TESARO, TOGETHER with TESARO, ZEJULA, and the logo designs presented in this material are trademarks or registered trademarks of TESARO, Inc. © 2017 TESARO, Inc. All rights reserved. PP-ZEJ-US-0043

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

Section 8: 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 9: Requires a healthcare professional signature, either that of a prescriber or a legal representative from the office. A healthcare professional signature is required to attest to the review of the policy and consent. Patient signature is not required.

4 of 4

Instructions:Complete the first 3 pages of this form.

* Terms and conditions: The Quick Start Program helps eligible patients obtain ZEJULA at no cost for a limited time. To be eligible for the program, a patient must: (1) have a diagnosis consistent with the product package insert; (2) have a prescription for ZEJULA from their prescribing physician; (3) have insurance; and (4) be experiencing an insurance coverage delay of 5 business days or more.

– Benefits Investigation

– Prior Authorization Facilitation and Appeals Support

– Quick Start and Bridge Programs

– Commercial Co-pay Assistance Program

– Referrals to Patient Advocacy Organizations





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

Healthcare Professional to sign and date Section 9.

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 and may assist with the prior authorization process.

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: The Quick Start Program is optional and may be pursued for eligible patients who are experiencing payer-related delays in coverage determination. These patients will be provided a free 15-day supply of ZEJULA. Terms and conditions apply.* 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.

Select services requested to specify the needs of your patient.

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

– Patient Assistance Program (PAP)

Documents

TOGETHER with TESARO Enrollment Form · PDF file · 2017-11-20Call us at 1-844-2TESARO (1-844-283-7276), Monday-Friday (8 am to 8 pm ET) Fax us the completed enrollment form at