PATIENT ASSISTANCE PROGRAMS Definitions

Transcription

PATIENT ASSISTANCE PROGRAMS
Definitions
BCCA
SAP
Class I
Class II
BC Cancer Agency
Health Canada Special Access Program
Reimbursed for active cancer or approved treatment or approved indication only
Reimbursed for approved indications only. Completion of Class II Approval Form is necessary. In addition,
where indicated, approval from Tumour Group Chair or delegate is required for reimbursement
Reimbursement for approved indications only. Completion of the BCCA Compassionate Access Program
Application (formerly Undesignated Indication Form) is necessary to provide the appropriate clinical
information for each patient
Restricted Funding
The Patient Assistance Program chart is a general reference on the available programs offered by pharmaceutical manufacturers to help patients
access specific drug therapies. Inclusion in the chart does not imply BC Cancer Agency endorsement of any drug therapy that is not approved on
the BC Cancer Agency Benefit Drug List. Care has been taken to ensure accuracy of information; however it is not intended to replace specific
information as provided by the manufacturer. Since program requirements are constantly evolving, it is advised that this chart not be used as a
sole source of information.
Home injection programs
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
PHARMACARE
SPECIAL AUTHORITY
Buserelin
(SUPREFACT®)
Sanofi-Aventis
Class I
SUPREFACT® Home Injection Program
Medicum Patient Assistance Program
Tel: 1-877-787-3228
Fax: 1-877-787-3376
Assistance offered:
• Home delivery (weigh bills provided to
pharmacies to ship buserelin and charge to the
SUPREFACT® Community Care and Home
Injection Program)
• Home injection service (free of charge)
Not required
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
PHARMACARE
SPECIAL AUTHORITY
If you are aware of Patient Assistance Programs updates that you would like to see added to this chart, please contact: druginfo@bccancer.bc.ca
H:\Pharm-prov\Provincial DI Coordinator\Protocol\Patient Assistance Programs
Created: Oct 17, 2008
Updated: 22 October 2014 (updated valacyclovir)
1/19
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
PHARMACARE
SPECIAL AUTHORITY
Degarelix
(FIRMAGON®)
Ferring
Class I
Not required
Goserelin
(ZOLADEX®)
Astra-Zeneca
Class I
Leuprolide
(ELIGARD®)
Sanofi-Aventis
Class I
Leuprolide
(LUPRON®)
TAP
Pharmaceuticals
Class I
FIRMAGON® Care Program
Tel: 1-866-872-5772
Fax: 1-877-722-2730
Assistance offered:
pharmacies to ship degarelix and charge to the
FIRMAGON® Care Program)
• Home injection service (free of charge) for nonambulatory patients near major centers (caseby-case basis in remote regions)
ZOLADEX® Community Care and Home
Injection Program
Tel: 1-866-733-7511
Fax: 1-866-733-7514
Assistance offered:
pharmacies to ship goserelin and charge to the
ZOLADEX® Community Care and Home
Injection Program) free of charge
ELIGARD® Home Injection Program
Tel: 1-877-787-3228
Fax: 1-877-787-3376
Assistance offered:
pharmacies to ship leuprolide and charge to the
ELIGARD® Community Care and Home
Injection Program)
LUPRON® Comfort Program
Tel: 1-866-958-7766
Fax: 1-866-230-1398
Assistance offered:
• Help for patients to obtain third party coverage
• Financial assistance may be provided
Not required
Not required
Not required
2/19
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
PHARMACARE
SPECIAL AUTHORITY
Octreotide
(SANDOSTATIN®)
Novartis
Pharmaceuticals
Class I
Access SANDOSTATIN® LAR
Tel: 1-866-281-4688
Fax: 1-866-281-4689
Assistance offered:
• Help for patients to obtain third party coverage
• Financial assistance may be provided
Not required
3/19
Supportive care medications
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
Aprepitant
(EMEND®)
Merck
Funded by
BCCA for
approved
indications for
inpatient use
only.
Merck Canada Patient Assistance Program®
Tel: 1-866-906-3725
Fax: 1-800-754-0151
Assistance offered:
• Compassionate supply is available to patients
without third party insurance coverage
• Once certain criteria are met (i.e. proof of low
income) medication is delivered to prescriber’s
office or to a designated pharmacy to dispense and
for patient pick up
Fragmin® SmartSample Program
Tel: 1-800-563-3274
Assistance offered:
• Once prescribed by the physician, the physician will:
o Apply for PharmaCare Special Authority
o Give the patient a SmartSample® card
• The SmartSample® card entitles the patient to a few
free dalteparin pre-filled syringes from a community
pharmacy for use while waiting for PharmaCare
approval
o treatment doses (5 free syringes)
o prophylactic doses (10 free syringes)
VICTORY® Program
Tel: 1-888-706-4717
Fax: 1-888-987-2201
Assistance offered:
• Financial assistance is available to all patients who
have third party insurance coverage but may need
help with the co-pay
• Darbepoetin will be shipped by Victory program to a
designated pharmacy
• Program to be initiated before patient goes to
pharmacy
Dalteparin
(FRAGMIN®)
Darbepoetin
(ARANESP®)
Pfizer
Amgen
Funded by
BCCA for
approved
indications for
inpatient use
only.
Not funded by
BCCA
PHARMACARE
SPECIAL AUTHORITY
PharmaCare Special
Authority required.
Please fax form General
Special Authority Request
to PharmaCare
Fax: 1-800-609-4884
PharmaCare Special
Authority required.
Please fax form Venous
Thromboembolic Disease
to PharmaCare
Fax: 1-800-609-4884
Not required
4/19
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
Epoetin Alfa
(EPREX®)
Janssen
Not funded by
BCCA
Filgrastim
(NEUPOGEN®)
Amgen
Funded by
BCCA for
approved
indications for
inpatient use
only.
SPECTRUM Support Program for Eprex®
Tel: 1-877-793-7739
Fax: 1-888-298-8854
Assistance offered:
• A compassionate supply is available to patients
without third party insurance coverage, based on
financial needs
• SPECTRUM program coordinates delivery with
patients preferred pharmacy
• Initial self injection training with Nurse available in
most regions. SPECTRUM program will coordinate
nurse home visit with patient
VICTORY® Program
Tel: 1-888-706-4717
Fax: 1-888-987-2201
Assistance offered:
• Victory® Program will assist with the co-pay based
on financial need and Fair PharmaCare deductible
for each patient
• Compassionate supply will be shipped by Victory®
program to a designated pharmacy.
• Program to be initiated and PharmaCare approval
established before patient goes to the pharmacy
PHARMACARE
SPECIAL AUTHORITY
Not required
PharmaCare Special
Authority required prior to
program being initiated.
Please fax form
Filgrastim (GCSF) to
PharmaCare
Fax: 1-800-609-4884
5/19
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
Pegfilgrastim
(NEULASTA®)
Amgen
Not funded by
BCCA
Valacyclovir
(VALTREX®)
GlaxoSmithKline
Not funded by
BCCA
VICTORY® Program
Tel: 1-888-706-4717
Fax: 1-888-987-2201
Assistance offered:
• Compassionate supply will be shipped by Victory®
program to a designated pharmacy
• If patient is prescribed NEULASTA® and has no
third party coverage, they will be offered
NEUPOGEN®
• Program to be initiated before patient goes to
pharmacy
VALTREX® Patient Assist Program
Tel: 1-844-794-3577
Web: https://www.rxhelp.ca/Valtrex
Assistance offered:
• The VALTREX® Patient Assist Program will cover
up to the difference between the out of pocket
amount of branded VALTREX® (valacyclovir
hydrochloride) versus the out of pocket amount a
patient would have paid based on the average
generic drug price.
• This amount will vary depending on each patient’s
coverage (i.e., public, private, none) in each
province.
• Patients must first have their prescription filled at a
community pharmacy and have the receipt when
they call the program
PHARMACARE
SPECIAL AUTHORITY
Not required
Not required
6/19
Drugs with assistance/reimbursement programs and/or coordination of insurance coverage
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
Abiraterone
(ZYTIGA®)
Janssen
Restricted
Funding
ZYTIGA® Access Program (ZAP)
Tel: 1-855-998-4423
Fax: 1-855-998-4424
Assistance offered:
• Financial assistance is available to all patients with
or without third party insurance
• No compassionate supply available
• Home delivery available through McKesson
Pharmacy
• Home delivery of one blood pressure monitor per
patient available
PHARMACARE
SPECIAL AUTHORITY
Not required
7/19
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
Afatinib
(GIOTRIF®)
Boehringer
Ingelheim
Restricted
Funding
Axitinib
(INLYTA®)
Pfizer
Restricted
Funding
Bevacizumab
(AVASTIN®)
Roche
Class II or
Restricted
Funding based
on indication
Bendamustine
(TREANDA®)
Lundbeck
Restricted
Funding
HeadStart Patient Assistance Program
Tel: 1-800-987-9080
Fax: 1-800-637-3515
Assistance offered:
• Home delivery available through BioScript
Pharmacy
Pfizer Oncology Reimbursement Assistance
Program - Inlyta®
Tel: 1-888-963-4778
Fax: 1-877-787-3376
Assistance offered:
• Financial assistance is available to eligible patients
with third party insurance coverage but may need
Roche Patient Assistance Program
Tel: 1-888-748-8926
Fax: 1-888-532-1198
Assistance offered:
third party insurance coverage but may need help
with the co-pay
• Infusion coordination provided if required
TREANDA® Patient Support Program
Tel: 1-855-489-6576
Fax: 1-855-212-7875
Assistance offered:
PHARMACARE
SPECIAL AUTHORITY
Not required
Not required
Not required
Not required
8/19
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
Bosutinib
(Bosulif®)
Pfizer
Not funded by
BCCA
Capecitabine
(XELODA®)
Roche
Class II or
Restricted
Funding based
on indication
Crizotinib
(XALKORI®)
Pfizer
Restricted
Funding
Pfizer Reimbursement Assistance Program
Tel: 1-888-963-4778
Fax: 1-877-787-3376
Assistance offered:
• Financial assistance is available to patients with or
without third party insurance
• Compassionate supply may be available
Tel: 1-888-748-8926
Fax: 1-888-532-1198
Assistance offered:
XALKORI® Reimbursement Support Program
First Resource Program (Medicum)
Tel: 1-888-963-4778
Fax: 1-877-787-3376
Assistance offered:
• Compassionate supply available for patients who
qualify
• Crizotinib will only be provided to patients who have
tested ALK-positive using a validated ALK assay at
a laboratory with demonstrated proficiency in the
specific technology
• Program does not coordinate or cover cost of ALK
testing
PHARMACARE
SPECIAL AUTHORITY
Not required
Not required
Not required
9/19
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
Dabrafenib
(TAFINLAR®)
GlaxoSmithKline
Not funded by
BCCA
Denosumab
(XGEVA®)
Amgen
Not funded by
BCCA
Doxorubicinpegylated
liposomal
(CAELYX®)
Janssen
Class II
inReach Patient Support Program
Tel: 1-888-475-4255
Fax: 1-888-475-3291
Assistance offered:
without third party insurance. Patients may be asked
to co-pay based on household income.
• Patient must be BRAF-positive
• Program does not coordinate or cover cost of BRAF
testing
Pharmacy
VICTORY® Program
Tel: 1-888-706-4717
Fax: 1-888-987-2201
Assistance offered:
Richard K. Plante, Director of Oncology, Janssen
Tel: 416-382-5078
Mobile: 416-805-4648
e-mail: rplante@its.jnj.com
Enzalutamide
(XTANDI®)
Astellas
Restricted
Funding
or Myrna O’ Brodovich, Medical Information, Janssen
Tel: 1-800-567-3331
e-mail: medinfocanada@joica.jnj.com
XTANDI® Patient Assistance Program
Tel: 1-855-982-6348
Fax: 1-855-982-6349
Assistance offered:
Pharmacy
PHARMACARE
SPECIAL AUTHORITY
Not required
Not required
Not required
Not required
10/19
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
Eribulin
(HALAVEN®)
Eisai
Restricted
Funding
Erlotinib
(TARCEVA®)
Roche
Class II or
Restricted
Funding based
on indication
Everolimus
(AFINITOR®)
Novartis
Class II or
Restricted
Funding based
on indication
Eisai Assistance Program
Tel: 1-866-601-7340
Fax: 1-866-246-7195
Assistance offered:
Tel: 1-888-748-8926
Fax: 1-888-532-1198
Assistance offered:
AfiniTRAC® Reimbursement Support Program
Tel : 1-888-623-4648
Fax : 1-866-359-0175
Assistance offered:
PHARMACARE
SPECIAL AUTHORITY
Not required
Not required
Not required
11/19
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
Fulvestrant
(FASLODEX®)
AstraZeneca
Not funded by
BCCA
FasloCARE Program
Tel: 1-877-327-5644
Fax: 1-877-327-5655
Assistance offered:
• Compassionate supply may be available
Pharmacy
PHARMACARE
SPECIAL AUTHORITY
Not required
Astra Zeneca Patient Assistance Program
Tel: 1-800-668-6000
Fax: 1-800-268-0774
Assistance offered:
• For patients < 65 years of age: 1-3 month
compassionate supply is available to patients
without third party insurance coverage AND cannot
self pay; medication is sent directly to requesting
physician’s address; supply is renewable
Imatinib
(GLEEVEC®)
Novartis
Class II
Interferon alpha
(INTRON A®)
Merck
Class I
Faslodex® Patient Benefit Program
Assistance offered:
• Program covers up to 20% of drug cost
• Patient benefit card can be downloaded from
www.innovi.ca and used multiple times
GIST Alliance
Tel: 1-855-489-4362
Fax: 1-855-788-3159
Assistance offered:
TM
Merck Care Oncology
Tel: 1-877-494-0454
Fax: 1-877-656-0686
Assistance offered:
Not required
Not required
12/19
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
Ipilimumab
(YERVOY®)
Bristol-Myers
Squibb
Restricted
Funding
Lapatinib
(TYKERB®)
GlaxoSmithKline
Restricted
Funding
Lenalidomide
(REVLIMID®)
Celgene
Restricted
Funding
Letrozole
(FEMARA®)
Novartis
Pharmaceuticals
Class I
YERVOY® Access to Hope Program
Tel: 1-877-967-6626
Fax: 1-800-572-4971
Assistance offered:
• Enrolment criteria: not for off-label indications
• Financial assistance and compassionate supply
available to all patients with or without third party
insurance coverage on a case-by-case evaluation
• Prescribers must complete a certification program
prior to prescribing the drug via
https://www.bmscanada.ca/en/health-careprofessionals/yervoy-tools-for-healthcareprofessionals-and-patients
inReach® Patient Support Program
Tel: 1-888-475-4255
Fax: 1-888-475-3291
Assistance offered:
to co-pay based on household income
RevAid® program
Tel: 1-888-738-2431
Fax: 1-877-585-2382
Website: www.revaid.ca
Assistance offered:
• Compassionate supply may be available for nonBCCA funded indications
Access FEMARA®
Tel: 1-888-233-6272
Fax: 1-800-808-4964
Assistance offered:
• Compassionate supply of FEMARA® available
based on financial need
PHARMACARE
SPECIAL AUTHORITY
Not required
Not required
Not required
Not required
13/19
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
Nilotinib
(TASIGNA®)
Novartis
Restricted
Funding
Pazopanib
(VOTRIENT®)
GlaxoSmithKline
Restricted
Funding
Pemetrexed
(ALIMTA®)
Lilly
Class II or
Restricted
Funding based
on indication
Pertuzumab
(PERJETA®)
Roche
Restricted
Funding
GIST Alliance
Tel: 1-855-489-4362
Fax: 1-855-788-3159
Assistance offered:
inReach® Patient Support Program
Tel: 1-888-475-4255
Fax: 1-888-475-3291
Assistance offered:
ALIMTA® Assistance with Reimbursement of Cost
(ARC) Program
Tel: 1-888-425-4682
Fax: 1-877-787-3376
Assistance offered:
• Coordination of third party insurance coverage,
including WorkSafeBC
• Based on financial need:
o Financial assistance may be available to
patients who have third party insurance
coverage but may need help with the copay
o Compassionate supply may be available
Roche Patient Assistance Program (RPAP)Perjeta®
Tel: 1-855-224-2233
Fax: 1-855-212-7977
Assistance offered:
PHARMACARE
SPECIAL AUTHORITY
Not required
Not required
Not required
Not required
14/19
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
Pomalidomide
(POMALYST®)
Celgene
Not funded by
BCCA
Regorafenib
(STIVARGA®)
Bayer
Not funded by
BCCA
Romidepsin
(ISTODAX®)
Celgene
Not funded by
BCCA
Pomalyst Access Program
Assistance offered:
• Program opens for enrolment until December 31,
2014 once drug is commercially available in Canada
in 2014
• Enrolment criteria: failed Bortezomib and
Lenalidomide
or without third party insurance coverage
• Compassionate drug supply may be available
ABC STIVARGA program
Tel: 1-855-327-4511
Fax: 1-855-206-9788
Assistance offered:
• Financial assistance available to all patients with or
ISTODAX Access Program
Tel: 1-289-291-4841
Fax: 1-888-306-5830
Assistance offered:
• Program opens for enrolment until March 31, 2015
• Compassionate supply available to patients enrolled
prior to March 31, 2014
• Enrolment criteria: relapsed/refractory Peripheral TCell Lymphoma (PTCL) not eligible for stem cell
transplant; failed at least one prior systemic therapy
• Financial assistance available to all patients with or
• No infusion cost assistance
PHARMACARE
SPECIAL AUTHORITY
Not required
Not required
Not required
15/19
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
Rituximab
(RITUXAN®)
Roche
Class II or
Restricted
Funding based
on indication
Romiplostim
(NPLATE®)
Amgen
Not funded by
BCCA
Ruxolitinib
(JAKAVI®)
Novartis
Restricted
Funding
Sorafenib
(NEXAVAR®)
Bayer
Restricted
Funding
Tel: 1-888-748-8926
Fax: 1-888-532-1198
Assistance offered:
eNable Support Program
Tel: 1-888-675-2832
Fax: 1-888-675-2835
Assistance offered:
• No compassionate assistance available
Novartis Alliance Program- MPN Alliance
Tel : 1-855-489-4362
Fax : 1-855-788-3159
Assistance offered:
Assistance Bayer Canada (ABC) NEXAVAR®
Program
Tel: 1-800-639-2827
Fax: 1-866-246-7796
Assistance offered:
PHARMACARE
SPECIAL AUTHORITY
Not required
Not required
Not required
Not required
16/19
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
Temozolomide
(TEMODAL®)
Merck
Class II
Thalidomide
(THALOMID®)
Celgene
Restricted
Funding
Tocilizumab
(ACTEMRA®)
Roche
Not funded by
BCCA
Trametinib
(Mekinist®)
GlaxoSmithKline
Not funded by
BCCA
Merck Care Oncology
Tel: 1-877-494-0454
Fax: 1-877-656-0686
Assistance offered:
RevAid® program
Tel: 1-888-738-2431
Fax: 1-877-585-2382
Website: www.revaid.ca
Assistance offered:
• Compassionate supply may be available for nonBCCA funded indications
JointEffort® program
Tel: 1-888-748-8926
Fax: 1-888-532-1198
Assistance offered:
inReach Patient Support Program
Tel: 1-888-475-4255
Fax: 1-888-475-3291
Assistance offered:
• Patient must be BRAF-positive
• Program does not coordinate or cover cost of BRAF
testing
Pharmacy
TM
PHARMACARE
SPECIAL AUTHORITY
Not required
Not required
Not required
Not required
17/19
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
Trastuzumab
(HERCEPTIN®)
Roche
Class II or
Restricted
Funding based
on indication
Trastuzumab
Emtansine
(KADCYLA®)
Roche
Restricted
Funding
Vandetanib
(CAPRELSA®)
AstraZeneca
Not funded by
BCCA
Tel: 1-888-748-8926
Fax: 1-888-532-1198
Assistance offered:
• Infusion coordination provided, if required
Roche Patient Assistance Program (RPAP)Kadcyla®
Tel: 1-855-224-2233
Fax: 1-855-212-7977
Assistance offered:
• Infusion coordination provided, if required
CAPRELSA® Restricted Distribution Program
Tel: 1-800-668-6000
Website: www.caprelsa.ca/rdp.
Assistance offered:
• Prescribing physicians and pharmacists need to
complete a certification process and register with
the program in order to enrol patients, prescribe and
dispense vandetanib (CAPRELSA®).
• No compassionate supply of vandetanib offered by
program
• Reimbursement guidance for patients with third
party insurance coverage offered by Shoppers Drug
Mart Specialty Health Network. Tel: 1-855-212-3922
See: Drugs with Special Ordering Procedures (SAP
chart)
PHARMACARE
SPECIAL AUTHORITY
Not required
Not required
Not required
18/19
DRUG
SUPPLIER
BCCA CLASS
PROGRAM INFORMATION
Vemurafenib
(ZELBORAF®)
Roche
Restricted
Funding
Vismodegib
(ERIVEDGE®)
Roche
Restricted
Funding
Roche Patient Assistance Program (RPAP)
Tel: 1-888-748-8926
Fax: 1-888-532-1198
Assistance offered:
Roche Patient Assistance Program/ERIVEDGE®
Pregnancy Prevention Program (RPAP/EPPP)
Tel: 1-888-748-8926
Fax: 1-888-532-1198
Assistance offered:
• Drug can only be dispensed to patients who are
registered and meet all conditions of the EPPP. For
more information contact EPPP at 1-888-748-8926
PHARMACARE
SPECIAL AUTHORITY
Not required
Not required
19/19

PATIENT ASSISTANCE PROGRAMS Definitions

Transcription

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