Veloxis Transplant Support PAP Program Enrollment Form

Patient Assistance Program Enrollment
The ENVARSUS XR® PATIENT SUPPORT PROGRAM (“PAP Program”) provides ENVARSUS XR® at no cost for eligible patients who have been prescribed ENVARSUS XR® for an FDA-approved indication and meet certain criteria. Applications are reviewed, and eligibility verified. Determinations are made on a case-by-case basis using pre-determined eligibility requirements regarding coverage and financial criteria.
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{{Benefits Investigation}}

{{Benefits Investigation}} Benefits Investigation / Verification Only
Patient Contact Information
1. First Name{{Patient First Name}} *
2. Last Name{{Patient Last Name}} *
3. Date of Birth{{DOB}} 3. Date of Birth{{DOB}} * / MM / DD YYYY

This field is required
4. Birth Sex{{Birth Sex}}

4. Birth Sex{{Birth Sex}} Male Female
5. Home Address {{Home Address}} *
6. City {{City}} *
7. State{{State}} *
8. Zip Code{{Zip Code}} *
9. Phone # ( Home / Cell ) {{Phone #}} 9. Phone # ( Home / Cell ) {{Phone #}} * - ### - ### ####
10. Preferred Language (if not English):{{Preferred language}}
11. Email{{Email}}
12. Ok to Text? (Select one){{Text Msg}}

12. Ok to Text? (Select one){{Text Msg}} Yes No
13. Ok to leave voicemail? (Select one){{Voicemail}}

13. Ok to leave voicemail? (Select one){{Voicemail}} Yes No
14. Additional Contact (person authorized to speak on your behalf):
14(a). Phone Number 14(a). Phone Number - ### - ### ####
Patient Insurance Information

Complete section OR include copies of the insurance cards (front and back)
15. Pharmacy Benefit Plan Name:
15(a). Policy Holder Name
15(b). Insurance Phone #: 15(b). Insurance Phone #: - ### - ### ####
15(c). Rx BIN:
15(d). Rx PCN:
15(e). ID #:
15(f). Rx Group #:
16. Patient has (check all that apply): *

16. Patient has (check all that apply): No Insurance Medicare B Medicare Advantage Medicaid Private/Commercial Government (TRICARE/VA)
17. Primary Insurance
17(a). Primary Insurance Name:
17(b). Policy Holder Name: 17(b). Policy Holder Name: First Last
17(c). Insurance Phone #: 17(c). Insurance Phone #: - ### - ### ####
17(d). Policy ID #:
17(e). Group ID #:
Upload Primary Insurance Card Image (optional):

Attach Files
Does the patient have secondary insurance? *

Does the patient have secondary insurance? Yes No
18. Secondary Insurance
18(a). Secondary Insurance Name:
18(b). Policy Holder Name: 18(b). Policy Holder Name: First Last
18(c). Insurance Phone #: 18(c). Insurance Phone #: - ### - ### ####
18(d). Policy ID #:
18(e). Group ID #:
Upload Secondary Insurance Card Image (optional):

Attach Files
Healthcare Provider Information
19. Prescriber First Name *
20. Prescriber Last Name *
21. Specialty
22. Title (select one):

22. Title (select one): MD DO NP PA other (specify): other (specify):
23. Prescriber NPI #: *
24. Tax ID #:
25. Facility Name:{{Facility Name}}
26. Facility Address:
27. City:
28. State:{{Facility State}}
29. Zip Code:
30. Facility Phone:{{Facility Phone #}} 30. Facility Phone:{{Facility Phone #}} - ### - ### ####
31. Facility Fax:{{Facility Fax #}} 31. Facility Fax:{{Facility Fax #}} - ### - ### ####
32. Facility/Office Contact Name{{Facility Contact Name}} *
32(a). Contact Phone Number (Cell){{Contact phone #}} 32(a). Contact Phone Number (Cell){{Contact phone #}} * - ### - ### ####
32(b). Contact Email (Optional):
32(c). Preferred method of contact (select one):{{Prescriber Preferred contact method}} *

32(c). Preferred method of contact (select one):{{Prescriber Preferred contact method}} Facility Phone Cell Phone Email Fax
32(d). If a PA is required, would you like VTS to initiate the PA through CoverMyMeds:{{PA Required}}

32(d). If a PA is required, would you like VTS to initiate the PA through CoverMyMeds:{{PA Required}} Yes No
Patient Clinical Information
33. Diagnosis (select one):{{Diagnosis}} *

33. Diagnosis (select one):{{Diagnosis}} Z94.0 Kidney Transplant Status (ICD-10) Other (specify) Other (specify)
34. Date of Transplant:{{Date of Transplant}} 34. Date of Transplant:{{Date of Transplant}} * / MM / DD YYYY
35. Did Medicare pay for transplant (select one)? *

35. Did Medicare pay for transplant (select one)? Yes No
36. Estimated total daily dose of ENVARSUS XR® (tacrolimus extended-release tablets)*:{{Estimated Daily Dose}} *
36(a). Milligram Strength Prescribed* *

36(a). Milligram Strength Prescribed* 0.75 mg 1 mg 4 mg
37. Has a 30-day free trial of ENVARSUS XR® (tacrolimus extended-release tablets) been provided to the patient? (select one):

37. Has a 30-day free trial of ENVARSUS XR® (tacrolimus extended-release tablets) been provided to the patient? (select one): Yes No
37(a). If yes, date provided:{{Trial Start Date}} 37(a). If yes, date provided:{{Trial Start Date}} / MM / DD YYYY
Health Care Provider Certification/ Agreement

By submitting this form, I certify the following statements. To the best of my knowledge the information provided in this form is accurate and the patient currently meets the financial need and eligibility requirements of the ENVARSUS XR® PATIENT SUPPORT PROGRAM, including without limitation, the requirement that the patient be prescribed ENVARSUS XR® for an FDA-approved indication. The patient understands and agrees to comply with the Terms and Conditions (as shown on page 4). If I become aware the patient may no longer meet the criteria for the program, I agree to notify ENVARSUS XR® PATIENT SUPPORT PROGRAM. I have received written authorization from the above-named patient (or the patient’s legal representative) as required by applicable federal and state laws to disclose the patient’s personal information, medical information and insurance information to Veloxis Pharmaceuticals, Inc. (“Veloxis”) and its authorized agents, employees, and representatives (collectively “Authorized Representatives”). Patient (or the patient’s legal representative) has consented to and directed disclosure of patient’s information to Authorized Representatives for the purpose of assessing whether the patient qualifies for the ENVARSUS XR® PATIENT SUPPORT PROGRAM (in accordance with its terms) and to administer the ENVARSUS XR® PATIENT SUPPORT PROGRAM for the duration of patient’s therapy. ENVARSUS XR® is medically necessary for this patient. I agree that my Facility will not submit, or cause to be submitted, any claims for payment or reimbursement to any third-party payor, including any federal healthcare program, such as Medicare or Medicaid, for ENVARSUS XR® or other support that may be provided through the ENVARSUS XR® PATIENT SUPPORT PROGRAM. I understand that prescribers are under no obligation to prescribe any Veloxis product to participate in ENVARSUS XR® PATIENT SUPPORT PROGRAM and have not and will not receive any benefit from Veloxis for prescribing a Veloxis product. Veloxis may change, terminate, or suspend my participation in the program without prior notice.
Printed Name:{{Prescriber name}} *
Signature: *

Clear
Date of Signature:{{Date of HCP Signature}} Date of Signature:{{Date of HCP Signature}} * / MM / DD YYYY
Other Supporting Documents:

Attach Files
This form does not constitute a valid prescription.
Is the patient currently available to authorize enrollment into the ENVARSUS XR® Patient Support Program? *

Is the patient currently available to authorize enrollment into the ENVARSUS XR® Patient Support Program? Yes No
Eligibility Criteria /
Patient Personal Health Information
Eligibility Criteria

• Patient is commercially or federally insured or uninsured.
• Patient meets financial eligibility criteria.
• Patient is being treated for an FDA-approved indication.
• Patient must be 18 years or older. For patients who are 17 years of age, the patient’s parent or legal guardian must complete the enrollment and obtain ENVARSUS XR® on behalf of the patient.
• Patient is a legal, permanent resident of the United States and its territories including Puerto Rico.
Patient Protected Health Information

I authorize my healthcare providers, pharmacies, insurance providers, and payers to use, share, and disclose my personal and health information, including information about my insurance benefits, prescriptions, medical condition and history, adherence to my treatment, my general health, and my sensitive health (e.g., communicable diseases (HIV, hepatitis), drug/alcohol abuse, mental health, genetic testing, etc.), (collectively, “Personal Information”) with Veloxis Pharmaceuticals, Inc. (“Veloxis”) and its authorized agents and representatives (collectively “Authorized Representatives”) to: (1) establish my benefit eligibility; (2) provide support services related to ENVARSUS XR®, including facilitating the provision of medication to me; (3) contact me to evaluate therapy and the effectiveness of the ENVARSUS XR® PATIENT SUPPORT PROGRAM; (4) provide me with disease management and other educational materials. I understand that once my Personal Information has been disclosed to the Authorized Representatives, it may no longer be protected by federal privacy law and applicable state laws, and may be subject to redisclosure. I understand that any entity authorized to support the ENVARSUS XR® PATIENT SUPPORT PROGRAM and any specialty pharmacies providing my health information and/or support to me in connection with the ENVARSUS XR® PATIENT SUPPORT PROGRAM may receive remuneration from Veloxis.

I understand that I do not need to sign this authorization in order to receive healthcare treatment from my healthcare provider(s), insurance benefits, or enrollment in a health plan. However, I understand that if refuse to sign this authorization, I will not be eligible to participate in the ENVARSUS XR® PATIENT SUPPORT PROGRAM, even if I meet the criteria. I understand that I may provide written notice of revocation of this authorization at any time by sending a notice to help@veloxistransplantsupport.com. I understand that my revocation shall not apply to any of my Personal Information that has already been used or disclosed through this authorization before Veloxis Transplant Support received notice of my written revocation. If I revoke my authorization, I understand I will no longer be eligible to participate in the ENVARSUS XR® PATIENT SUPPORT PROGRAM. I understand my authorization will remain in effect for 3 years or the maximum period permitted under applicable law, if shorter. I may obtain a copy of this Authorization by contacting ⁠help@veloxistransplantsupport.com.
Patient’s or Patient Representative's Printed Name *
Patient’s or Patient Representative's Signature *

Clear
Today's Date Today's Date * / MM / DD YYYY
Relationship to Patient (if not self):

Relationship to Patient (if not self): Legal guardian Caregiver
Choose ELECTRONIC or PAPER income verification
{{Income verification}} *

{{Income verification}} OPTION 1: ELECTRONIC INCOME VERIFICATION

I authorize Veloxis Transplant Support, and its Authorized Representatives, to attempt to verify my household income electronically.

If the electronic check cannot verify my household income or the electronic check returns a result that my household income does not meet the qualifications and I wish to appeal, I understand that I will need to follow the Paper Income Verification steps outlined in Option 2. OPTION 2: PAPER INCOME VERIFICATION

I will provide documentation that shows my HOUSEHOLD INCOME PER YEAR.
Household Income Per Year: *
Including me, I/We have (number) of dependents in our household. *
CHOOSE ALL SOURCES OF INCOME:

I am INCLUDING proof that I/We (spouse or partner) receive income from the following:

CHOOSE ALL SOURCES OF INCOME:

I am INCLUDING proof that I/We (spouse or partner) receive income from the following: I/We earn salary or hourly wages from a job I/We have veterans’ benefits I/We have social security income I/We have workers’ compensation I/We have unemployment compensation I/We have alimony/child support I/We have pension/retirement income
Upload Proof of Household Income Documentation

Attach Files
Proof of household income documentation will be required to determine eligibility for the PAP. Acceptable forms of documentation to provide proof of annual household income as reported above include the most recent copy of (1) US federal tax returns, (2) Social Security income statements, (3) recent pay stubs (the two most recent), or (4) unemployment or disability statements.
Patient Certification/Agreement

• My application is complete and accurate.
• I meet the ENVARSUS XR® PATIENT SUPPORT PROGRAM eligibility criteria, as shown on this application.
• I will promptly provide documentation supporting the information I have provided in this application (e.g., income verification documents) if such documentation is requested by Authorized Representatives. Failure to promptly provide documentation when requested may result in termination of application review or removal from the ENVARSUS XR® PATIENT SUPPORT PROGRAM if my application has already been approved.
• I understand that I am providing “written instructions” to Veloxis Transplant Support under the Fair Credit Reporting Act authorizing Veloxis Transplant Support to obtain information from my personal credit profile or other information from a credit reporting agency (including, but not limited to, Experian Health). I authorize Veloxis Transplant Support to obtain such information solely to conduct an electronic income verification for credit.
• I understand Authorized Representative may request proof of my annual income as a requirement of enrollment.
• I understand that completing this enrollment form does not guarantee that I will qualify for the ENVARSUS XR® PATIENT SUPPORT PROGRAM.
• I understand my eligibility for the ENVARSUS XR® PATIENT SUPPORT PROGRAM is not conditioned on any use of Veloxis’s designated hub pharmacy for any prescription fills that occur outside the Program.
• If my application is approved:
- I will notify ENVARSUS XR® PATIENT SUPPORT PROGRAM of changes to my income.
- I will not submit any claim for reimbursement to any third party or government insurer for any product provided to me through the ENVARSUS XR® PATIENT SUPPORT PROGRAM.
- If I have Medicare Part D coverage, I will not seek to have the cost/value associated with the medication I receive through the ENVARSUS XR® PATIENT SUPPORT PROGRAM counted as out-of-pocket costs for prescription drugs and I will inform my Part D Plan about my enrollment.
- I will not sell, trade, or transfer any medication I receive through the ENVARSUS XR® PATIENT SUPPORT PROGRAM.
• I understand my certification will remain in effect for 3 years or the maximum period permitted under applicable law, if shorter. I may obtain a copy of this Certification by contacting help@veloxistransplantsupport.com
The information provided is current, complete, and accurate. I authorize Veloxis Pharmaceuticals, Inc. (“Veloxis”) and its authorized agents and representatives (collectively “Authorized Representatives”), to use this information to provide support for ENVARSUS XR®, and I agree to receive phone calls, emails, or text messages to communicate with the Authorized Representatives (message and data rates may apply to such calls and messages). By providing my phone number and signing below, I authorize the Authorized Representatives to deliver or cause to be delivered to me telephonic sales and marketing calls (including artificial voice calls) or text messages using an automated system for the selection and dialing of telephone numbers or the playing of a recorded message when a connection is competed to my number, or the transmission of a prerecorded voicemail. These messages may concern my prescription, including reminders, and other information related to my health, which may include telephonic sales calls. I further consent to automated or prerecorded messages being played when the telephone is answered whether by me or someone else. Telephone calls may be monitored or recorded for quality and other purposes. Consent to such calls and text messages is not a condition of receipt of services. I agree to promptly alert the Authorized Representatives whenever I stop using a particular telephone number. Reply STOP to opt out of text messaging. I am not required to directly or indirectly sign this written agreement or to agree to enter into such an agreement as a condition of purchasing any property, goods, or services.
Patient’s or Patient Representatives’ Printed Name *
Patient’s or Patient Representative's Signature *

Clear
Today's Date Today's Date * / MM / DD YYYY
Patient’s or Patient Representative’s Phone: Patient’s or Patient Representative’s Phone: * - ### - ### ####
Relationship to Patient (if not self):

Relationship to Patient (if not self): Legal guardian Caregiver
Please click submit to begin the PAP Enrollment Process for your patient. Thank you from your Veloxis Transplant Support Team!

If you have any questions please call us at 1-844-VELOXIS (835-6947).
©2024 Veloxis Pharmaceuticals, Inc. US-ENV-2400021 v2.0 7/24
Veloxis and ENVARSUS XR® are registered trademarks of Veloxis Pharmaceuticals, Inc.
All other trademarks are property of their respective owners.
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Veloxis Transplant Support PAP Program Enrollment Form

Patient Assistance Program Enrollment

Download Enrollment Form (PDF)

Veloxis Transplant Support Prescription Form

Bridge Program Enrollment Form

Patient Contact Information

Patient Insurance Information

17. Primary Insurance

18. Secondary Insurance

Healthcare Provider Information

Patient Clinical Information

Health Care Provider Certification/ Agreement

This form does not constitute a valid prescription.

Eligibility Criteria / Patient Personal Health Information

Eligibility Criteria

Patient Protected Health Information

Choose ELECTRONIC or PAPER income verification

Patient Certification/Agreement

Please click submit to begin the PAP Enrollment Process for your patient. Thank you from your Veloxis Transplant Support Team! If you have any questions please call us at 1-844-VELOXIS (835-6947).

Eligibility Criteria /
Patient Personal Health Information

Please click submit to begin the PAP Enrollment Process for your patient. Thank you from your Veloxis Transplant Support Team!

If you have any questions please call us at 1-844-VELOXIS (835-6947).