REIMBURSEMENT SERVICES

Healthcare Professionals

Co-Pay Assistance Program for MYOBLOC

What is it?

The Co-Pay Assistance Program for MYOBLOC helps eligible patients with Cervical Dystonia (CD) afford the 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 U.S. resident, and who have commercial insurance coverage.2

How does the patient access the Co-Pay Assistance Program for MYOBLOC?

The patient or office staff can call 888-461-2255, Option 3, to enroll the patient in the Co-Pay Assistance Program.

To determine eligibility a Benefit Investigation will be run. Once the patient's insurance information is validated and it is has been verified that the patient meets eligibility requirements, the patient is conditionally approved for one injection.

The patient will receive a letter in the mail with the Enrollment Application to continue the program for one year.

How are co-pay assistance 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 co-pay assistance 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, or evidence of a claim payment by an insurer(s) is required with supporting evidence to establish out-of-pocket expenses before any such reimbursement is authorized by the Co-Pay Assistance Program for MYOBLOC. [See Reference 1 for Michigan, Rhode Island, and Minnesota residents].

Payment for eligible costs

Upon conditional approval into the program, eligible costs for the patient’s first injection may be submitted for payment. Conditional approval may be granted for a sixty (60) day period for applications submitted via online enrollment or enrollment by telephone. Final approval is not granted until the Co-Pay Assistance Program for MYOBLOC receives a signed document from the patient agreeing to the terms and conditions of the program.

The program administrator will verify that costs are eligible for payment. Payment for eligible costs will be issued to the site of care within five business days following receipt of information validating eligible out-of-pocket expenses.

Beyond the first injection, patients must have received a final determination of eligibility. A final determination of eligibility requires that the program has received the application for enrollment with all necessary information, the patient is determined to meet the program criteria, and such application includes the patient’s signature.

*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 Co-Pay 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 Co-Pay 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 Co-Pay Assistance Program for MYOBLOC. Massachusetts residents are not eligible to participate in the Co-Pay 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.

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