REIMBURSEMENT SERVICES

Healthcare Professionals

MYOBLOC Copay Program

What is it?

The MYOBLOC Copay Program assists eligible patients with cervical dystonia with their out-of-pocket expenses associated with MYOBLOC (rimabotulinumtoxinB) Injection and the related administration expenses. With no limit per injection, eligible patients may receive up to $4,000 per year of assistance with permitted out-of-pocket expenses.1

Who is Eligible?

Patients who are diagnosed with cervical dystonia (G24.3), a legal US resident, and who have commercial insurance coverage according to the terms and conditions of the program.2

How does the patient access the MYOBLOC Copay Program?

The patient or office staff can call 877-268-7697 to enroll the patient in the Copay Program. Once the patient's insurance information is validated and it is verified that the patient meets eligibility requirements, the patient is approved for the assistance.

How are copay funds paid on behalf of the patient?

Once eligible for participation, the patient's eligible out-of-pocket expenses may be paid directly to the site of care (administering office or pharmacy) on the patient's behalf, or to the patient as a reimbursement for out-of-pocket expenses they paid to the site of care.

Irrespective of who will receive the copay payment, the site of care must first file a claim for MYOBLOC and the related injection-administration expenses with the patient's private insurance carrier(s). An Explanation of Benefits that shows payment for MYOBLOC and the related injection expenses is required with supporting evidence to establish out-of-pocket expenses before any such reimbursement is authorized by the MYOBLOC Copay Program [See Reference 1 for Michigan, Rhode Island, and Minnesota residents].

Payment for eligible costs

Upon approval into the program, eligible costs for the patient’s MYOBLOC injections may be submitted for payment. The program administrator will verify that the costs are eligible for payment. Payment for eligible costs will be issued to the site of care via a virtual Mastercard number within two business days of the receipt of information validating eligible out-of-pocket expenses.

If the site of care requires a check reimbursement, that check will be issued and mailed within 3-4 weeks. Any pharmacy using the Copay Program may use the patient's card ID and RxBIN to process and receive payment on claims.

Terms and Conditions for Healthcare Providers

Terms and Conditions: 1. This offer is valid for commercially-insured patients only and is good for use only with a MYOBLOC prescription at the time the prescription is filled or after the product is administered to the patient. 2. Depending on insurance coverage, eligible insured patients may pay no more than zero dollars ($0) for MYOBLOC and the administrative services associated with MYOBLOC, up to a maximum savings limit of four thousand dollars ($4,000) per year. Patient out-of-pocket expense may vary. 3. This offer is not valid for patients enrolled in Medicare, Medicaid, or other federal or state healthcare programs, or private indemnity or HMO insurance plans that reimburse you for the entire cost of your prescription drugs. Patients may not use this Program if they are Medicare-eligible and enrolled in an employer-sponsored health plan or medical or prescription drug benefit program for retirees. 4. The offer is valid for one (1) year. 5. US WorldMeds reserves the right to rescind, revoke, or amend this offer without notice. 6. Offer good only in the USA, including Puerto Rico, at participating pharmacies or healthcare providers. 7. Void if prohibited by law, taxed, or restricted. 8. Residents of Michigan, Rhode Island, and Minnesota are not eligible for assistance with payment for injection or injection guidance-related costs, but may receive assistance with MYOBLOC. 9. This Program is not transferable. The selling, purchasing, trading, or counterfeiting of this Program is prohibited by law. 10. This Program is not insurance. 11. By redeeming this assistance, you represent that, to the best of your knowledge, the patient is eligible to participate in the Program and that you understand and agree to comply with the terms and conditions of this offer.

Terms and Conditions for Patients

Terms and Conditions: 1. This offer is valid for commercially-insured patients only and is good for use only with a MYOBLOC prescription at the time the prescription is filled or after the product is administered to the patient. 2. Depending on insurance coverage, eligible insured patients may pay no more than zero dollars ($0) for MYOBLOC and the administrative services associated with MYOBLOC, up to a maximum savings limit of four thousand dollars ($4,000) per year. Patient out-of-pocket expense may vary. 3. This offer is not valid for patients enrolled in Medicare, Medicaid, or other federal or state healthcare programs, or private indemnity or HMO insurance plans that reimburse you for the entire cost of your prescription drugs. Patients may not use this Program if they are Medicare-eligible and enrolled in an employer-sponsored health plan or medical or prescription drug benefit program for retirees. 4. The offer is valid for one (1) year. 5. US WorldMeds reserves the right to rescind, revoke, or amend this offer without notice. 6. Offer good only in the USA, including Puerto Rico, at participating pharmacies or healthcare providers. 7. Void if prohibited by law, taxed, or restricted. 8. Residents of Michigan, Rhode Island, and Minnesota are not eligible for assistance with payment for injection or injection guidance-related costs, but may receive assistance with MYOBLOC. 9. This Program is not transferable. The selling, purchasing, trading, or counterfeiting of this Program is prohibited by law. 10. This Program is not insurance. 11. By redeeming this assistance, you represent that you are an eligible patient and that you understand and agree to comply with the terms and conditions of this offer.

*Patients are free, at any time, to switch healthcare providers, practitioners, pharmacies, commercial insurers, or suppliers without affecting continued eligibility for assistance. If patients begin receiving benefits from a government program, they would become ineligible for the Copay Assistance Program for MYOBLOC.

Submitting an application for assistance does not guarantee funding will be available. If financial assistance is awarded, it will be provided on an annual basis. Applicants must reapply for assistance each year. Funding in any subsequent year(s) or timeframes is not guaranteed. The Copay Assistance Program for MYOBLOC may be modified or discontinued at any time.

NOTE: Reimbursement services are available only for those patients being treated with MYOBLOC for a therapeutic condition for which there is a reasonable expectation of reimbursement from a third-party payer. Physicians are responsible for identifying the clinical indication and documenting medical necessity for use of MYOBLOC. Questions regarding the clinical use of MYOBLOC should be directed to 1-888-461-2255, Option 2.

References:

  1. Including MYOBLOC drug co-insurance [J0587], injection co-insurance [CPT Code: 64616,] and injection guidance (such as EMG) co-insurance [CPT Codes: 95873, 95874]. Patients residing in Michigan, Rhode Island, and Minnesota are not eligible for assistance with payment for injection or injection guidance-related costs, but may receive assistance with MYOBLOC.
  2. Government insured patients, such as Medicare, Medicaid, TRICARE®, Department of Veterans Affairs, and other federal or state funded programs are not eligible for participation in the Copay Assistance Program for MYOBLOC. Massachusetts residents are not eligible to participate in the Copay Assistance Program for MYOBLOC. Patients residing in Michigan, Rhode Island, and Minnesota are not eligible for assistance with payment for injection or injection guidance-related costs, but may receive assistance with MYOBLOC.

MYOBLOC Copay Program Portal