The Lilly PatientOne Co-pay Program
With the Lilly PatientOne Co-pay Program, commercially insured, eligible patients treated with Portrazza pay no more than $25 per dose*
This offer is invalid for patients whose prescription claims are eligible to be reimbursed, in whole or in part, by any governmental program.
*Financial assistance is limited to the co-pay or coinsurance costs for doses of Portrazza and does not cover any additional costs, including, but not limited to, fees related to the administration of Portrazza.
Patient Eligibility Criteria†
†Additional patient terms and conditions will apply. See below for details.
§Financial assistance is limited to the co-pay or coinsurance costs for doses of Portrazza and does not cover any additional costs, including, but not limited to, fees related to the administration of Portrazza.
||Patient’s adjusted gross household income is not more than the greater of $100,000 or 500% of the FPL.
¶Patients who continue Portrazza treatment and wish to participate in the Lilly PatientOne Co-pay Program must re-enroll every 12-month period.
Income Cap Information: Based on 2015 FPL1
Step-By-Step: Application to Reimbursement
Step 1: Application
- Review program eligibility with your patient based upon the full criteria listed below
- Download an application form or call PatientOne at 1-866-4PatOne (1-866-472-8663) for a faxed copy
- Fax the completed application and income verification documents to 1-877-366-0585, and remind the patient to provide all required income documentation
- At least 1 proof of income is required. Possible documents to prove income are:
- Copy of W-2
- Copy of prior year tax return
- Copy of most recent pay stub
- Copy of Social Security check or awards letter
- Your patient’s application will be reviewed to determine eligibility
- For patients deemed eligible, the enrollment date will be the date the application was received
- The program benefits may apply to co-pay or coinsurance expenses for doses of Portrazza the patient received within 60 days prior to the enrollment date, but not prior to the date an application was submitted
Step 2: Enrollment
- After submitting the Lilly PatientOne Co-pay Program application for Portrazza, patients and providers will be informed by PatientOne of program enrollment status
- Approved patients will receive an enrollment letter and the co-pay card in the mail from PatientOne
- Providers will be informed of patients’ enrollment status through a faxed letter
- Remind patients to bring their co-pay card with them to their next appointment
- If you have any questions or challenges obtaining or processing the Lilly PatientOne Co-pay Card for Portrazza, please contact Lilly PatientOne at 1-866-4PatOne (1-866-472-8663).
Step 3: Filing Claim for Financial Assistance
- Please submit claims for financial assistance to Lilly PatientOne
- Required information:
- Member ID # from patient’s Lilly PatientOne Co-pay Card
- Primary health insurer Explanation of Payment/Remittance
- Electronic submission: TripleFin, LLC – Payer ID #64300
- Fax submission: 1-877-366-0585
- Include Claim Form CMS-1500 (physician office) or CMS-1450/UB-04 (hospital outpatient)
- Reimbursement claims must be submitted within 180 days of infusion to receive program benefits
- For additional direction regarding the filing of claims, please review the back of the Lilly PatientOne Co-pay Card for Portrazza, or call 1-866-587-7321
For more information about the Lilly PatientOne Co-pay Program, please visit www.LillyPatientOne.com or call 1-866-4PatOne (1-866-472-8663)
Charitable assistance foundations
Through Lilly PatientOne, there may be a way to help your underinsured patients get the treatment they need with less financial stress. If your patients can’t afford their co-pay or coinsurance, PatientOne provides information about a number of charitable assistance foundations that may be able to help. We can even connect you with a foundation. Please remember, funding availability changes weekly, so contact a PatientOne representative at 1-866-4PatOne (1-866-472-8663) for the most recent updates.
Lilly PatientOne Co-pay Program Terms and Conditions
Eligibility: (1) You have commercial insurance that covers Portrazza™ (necitumumab) injection, but your insurance does not cover the full cost; that is, you have a co-pay or coinsurance obligation. (2) You are not participating in any state or federal healthcare program, including, without limitation, Medicaid, Medicare, Medigap, CHAMPUS, DOD, VA, TRICARE, or any state, patient, or pharmaceutical assistance program; patients who move from commercial insurance to a state or federal healthcare program will no longer be eligible. (3) You are 18 years of age or older and are receiving Portrazza for an FDA-approved use. Please see a list of approved uses in the US Prescribing Information. (4) You are a resident of the United States or Puerto Rico. (5) Your adjusted gross household income is not more than the greater of $100,000 or 500% of the Federal Poverty Level (FPL). You must provide documented proof of your income, such as a copy of your most recent Federal Tax Return or Social Security Statement.
Program Benefits: (6) The patient must first pay a portion of their co-pay or coinsurance ($25 for each dose of Portrazza). The program will cover the remainder of the patient’s co-pay or coinsurance for Portrazza, up to a maximum of $42,000 during a 12-month enrollment period. (7) In order to receive program benefits, the patient or provider must submit an Explanation of Payment (EOP) form. The submitted form must include the name of the insurer and the plan, and show that Portrazza was the medication that was given. A claim for reimbursement must be submitted within 180 days of infusion to receive program benefits. (8) The program may provide assistance for co-pays or coinsurance for doses of Portrazza that the patient received within 60 days prior to the date of enrollment, but not prior to the date an application was submitted. The program will not provide support for doses of Portrazza that the patient received before the application was submitted. (9) Program benefits are limited to the co-pay or coinsurance costs for doses of Portrazza only. The program will not cover, and shall not be applied toward, the cost of any dosing procedure, any other healthcare provider service or supply charges or other treatment costs, or any costs associated with a hospital stay.
Program Timing: (10) The enrollment period is 12 months from the date of enrollment. (11) Patients must enroll by December 31, 2016, to be eligible to receive benefits. (12) Absent a change in Massachusetts law, effective July 1, 2017, Massachusetts residents will no longer be able to participate in this program.
Additional Terms and Conditions of Program: (13) Patients, pharmacists, and healthcare providers must not seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this program. Patients must not seek reimbursement from any health savings, flexible spending, or other healthcare reimbursement accounts for the amount of assistance received from the program. (14) Acceptance of this offer confirms that this offer is consistent with your insurance and that you will report the value of the co-pay assistance you receive as may be required by your insurance provider. (15) This offer is not valid with any other financial support program, Patient Assistance Program (PAP), discount, or incentive involving Portrazza. (16) Only valid in the United States and Puerto Rico; this offer is void where restricted or prohibited by law. (17) The program benefits are nontransferable. (18) This offer is not conditioned on any past, present, or future purchase, including additional doses. (19) The program is not insurance. (20) Lilly USA, LLC reserves the right to terminate, rescind, revoke, or amend this offer at any time without notice.
Reference: 1. US Department of Health and Human Services. 2015 Poverty Guidelines. http://aspe.hhs.gov/poverty/15poverty.cfm. Accessed September 9, 2015.
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