Novartis Patient Assistance Form – Fill Out and Use This PDF

www.PAP.Novartis.com

Phone: 1-(800)-277-2254 Fax: 1-(855)-817-2711 P.O. Box 52029, Phoenix, AZ 85072-2029

Novartis Patient Assistance Foundation, Inc. Monday-Friday 8:00 a.m. to 8:00 p.m. Eastern Time Zone

Thank you for your interest in the Novartis Patient Assistance Foundation, Inc. (NPAF)

Please visit www.PAP.Novartis.com for a complete list of medications and income requirements.

Eligibility Criteria – To be eligible, a patient must:

•Be a U.S. resident

•Meet the income requirements

•Have limited or no prescription coverage

Instructions

To see if you are eligible, you will need to complete Patient Sections 1-5 on the Patient Application:

•Patient Section 1: Fill out your information completely and accurately. This will allow us to review your case and determine your eligibility for our program.

•Patient Section 2: If you have insurance, you will need to include a copy, of both the front and back, of all insurance cards (covering medical and prescription). This will allow us to verify your benefit coverage.

•Patient Section 3: You will need to provide proof of your household’s gross income. You can choose ONE of the following options to verify your proof of income:

––To allow for quicker processing, we can perform an electronic income check. This will be done only to verify your income and will have NO effect on your credit score/rating. If you want this option, please note that you need to be 18 years or older. If you want to choose this option please read and check the Fair Credit Reporting Act (FCRA) Consent on the Patient Application for this optional service.

OR

––You can include a copy of your financial documents, which include the following:

•Patient Section 4: If you become enrolled, we can use our autodialer/automated system to remind you when your next refill order can be placed and we can text you eligibility and refill information. For this option, please read and check the Telephone Consumer Protection Act (TCPA) Consent if you want to allow us to contact you this way. This is optional and may be easier to help you manage your enrollment.

•Patient Section 5: We need you to read the Patient Authorization page to allow us to process your application, communicate with you and manage your enrollment. Please read, sign and date at the bottom of the Patient Application.

Lastly, work with your health care provider (HCP) to complete his/her sections of the application. If you have insurance and your policy requires a Prior Authorization, your HCP will need to obtain it and include it with their portion of the application.

Fax or mail your completed application to:

Fax: 1-(855)-817-2711 —OR— Mail: NPAF, P.O. Box 52029, Phoenix, AZ 85072-2029

PLEASE KEEP THIS PAGE FOR YOUR RECORDS.

www.PAP.Novartis.com Phone: 1-(800)-277-2254 Fax: 1-(855)-817-2711 P.O. Box 52029, Phoenix, AZ 85072-2029

Novartis Patient Assistance Foundation, Inc. Monday-Friday 8:00 a.m. to 8:00 p.m. Eastern Time Zone

Patient Authorization

I give permission for my health care providers (HCPs), pharmacies, service providers and their contractors (“Health Care Providers”), health insurer(s) and their contractors (“Insurers”), to disclose my personal information, including information about my insurance, prescriptions, medical condition, and health (“Personal Information”) to the Novartis Patient Assistance Foundation, Inc. (“NPAF”) so that NPAF can administer the NPAF program by: (i) providing me with access to the product which I am prescribed, (ii) helping to verify insurance coverage, (iii) providing me with information about Novartis products, (iv) providing me with medication reminders, and (v) conducting quality assurance, surveys, and/or other internal business activities in connection with the NPAF program.

I give permission to NPAF to disclose my Personal Information to my Health Care Providers, Insurer(s), caregivers, Novartis Pharmaceuticals Corporation, its affiliates, service providers, and agents (“Novartis”), for the purposes described above. I also give permission to NPAF to combine or aggregate any information collected from me with information NPAF may collect about me from other sources for the purpose of providing or administering program services.

authorization. I also may revoke (withdraw) this authorization with respect to NPAF at any time in the future by calling 1-(800)-277-2254 or writing to P.O. Box 52029, Phoenix, AZ 85072-2029.

My refusal or future revocation will not affect the commencement or continuation of my treatment by my HCPs; however, if I revoke this authorization, I may no longer be able to participate in programs administered by NPAF. If I revoke this authorization, NPAF will stop using or sharing my information (except as necessary to end my participation in NPAF) but my revocation will not affect uses and disclosures of Personal Information previously disclosed in reliance upon this authorization. I understand that this authorization will remain valid for five (5) years after the date of my signature, unless I revoke it earlier. I also understand that programs administered by NPAF may change or end at any time without prior notification. I understand that I may receive a copy of this authorization.

I agree to be contacted by NPAF by mail, e-mail, telephone calls, and text messages at the number(s) and address(es) provided on the NPAF application for all purposes described in this Patient Authorization. I also agree to be contacted by NPAF and others on its behalf by telephone calls and text messages made by or using an autodialer or prerecorded voice, at the number(s) provided on this form, for all non-marketing purposes, including but not limited to sending me materials and asking for my participation in surveys, and confirming that I am the subscriber for the

I understand that the Companies do not permit my Personal Information to be used by their business partners for their own separate marketing purposes. I understand and agree that Personal Information transmitted by e-mail and cell phone cannot be secured against unauthorized access.

PLEASE KEEP THIS PAGE FOR YOUR RECORDS.

www.PAP.Novartis.com Phone: 1-(800)-277-2254 Fax: 1-(855)-817-2711 P.O. Box 52029, Phoenix, AZ 85072-2029

Novartis Patient Assistance Foundation, Inc. Monday-Friday 8:00 a.m. to 8:00 p.m. Eastern Time Zone

Prescriber Application

SECTION 1: Prescriber Information

Prescriber Full Name: _________________________________________ Phone Number: _____________________ Fax: ____________________

Facility Name or Group Practice Name, if applicable: ___________________________________________________________________________

Office Coordinator Name: _____________________________________ Prescriber’s Office Address: ___________________________________

Suite #: _____________ City: _________________________________________ State: _____________________ Zip Code: ____________________

DEA/State License #: _____________________________________________ NPI #: _______________________________________________________

Email: ___________________________________________________________________________________________________________________________

SECTION 2: Patient History

Patient’s Name: __________________________ Date of Birth: _______/_______/_______  No known allergies

Allergies: ______________________________________________ Current Medications: __________________________________________________

SECTION 3: Prescription

Medication #1 Name: _____________________ Strength: _________ If an injectable, please specify:  Pen  Syringe  Cartridge

Directions: _________________________________________________________________________________________________________________

Quantity: ___________________  90 Days Supply*  Other: ____________ Refill:  1 year  Other: ______________________

ICD-10 (REQUIRED): _______________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

Medication #2 Name: _____________________ Strength: _________ If an injectable, please specify:  Pen  Syringe  Cartridge

Directions: _________________________________________________________________________________________________________________

Quantity: ___________________  90 Days Supply*  Other: ____________ Refill:  1 year  Other: ______________________

ICD-10 (REQUIRED): _______________________________________________________________________________________________________

*Prescriptions may be supplied in 30-, 60- or 90-day fills from your 90-day script above

NOTE: Please be aware, if a Prior Authorization (PA) is required for the Novartis product(s) requested, you will need to provide that PA # and date of approval, or attach a copy of the denial letter. If this is a January renewal, you will need to process and forward a new PA. If we do not receive this information with the HCP portion of the application there may be a delay in processing for your patient.

SECTION 4: Prescriber Certification and Signature

Health Care Provider Authorization

I certify that the above therapy is medically necessary and that this information is accurate to the best of my knowledge. I certify that I am the physician who has prescribed the drug identified above to the previously identified patient. For the purposes of transmitting this prescription, I authorize NPAF and its affiliates, business partners, and agents to forward, as my agent for these limited purposes, this prescription electronically, by facsimile, or by mail to the appropriate dispensing pharmacies.

I certify that any medication received will be used only for the patient named on this form and will not be offered for sale, trade, or barter. Further, no claim for reimbursement will be submitted concerning this medication, nor will any medication be returned for credit. I acknowledge that NPAF is exclusively for purposes of patient care and not for remuneration of any sort. I understand that NPAF may revise, change, or terminate programs at any time.

Novartis Patient Assistance Foundation, Inc. (NPAF) Health Care Provider Authorization

I have read and agree to the Health Care Provider Authorization and authorize the above prescription:

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