Patient support for eligible and enrolled patients prescribed Increlex

Once the provider has prescribed Increlex® (mecasermin) injection, the IPSEN CARES® Patient Access Specialists are fully dedicated to:

  • Facilitating patients’ access to their prescribed medications
  • Providing information and support for the interactions among offices, patients, and insurance companies for Ipsen medications

HOW TO ENROLL IN IPSEN CARES PATIENT SUPPORT PROGRAM

IPSEN CARES provides a single point of contact for patients and their doctor’s office.

Please note: This form will take 10 minutes to complete. There is a requirement for two signatures - first the patient, then the HCP office.

Instructions for Patients

  • Your Healthcare Provider will complete the Steps Outlined in Green.
  • You need to complete Steps 1, 2, 3 and 8 Outlined in Purple on the Enrollment Form.
  • Fill out all sections completely. Required fields must be completed prior to submission of the form.
  • Required fields are marked with an asterisk.
  1. STEP 1: Fill out the Patient Information Section in Step 1.
  2. STEP 2: Fill out the Insurance Information Section in Step 2.
  3. STEP 3: Fill out the IPSEN CARES Copay Program Section in Step 3.
  4. STEP 4: Sign the PATIENT AUTHORIZATION AND ADDITIONAL PRODUCT AND SUPPORT INFORMATION box under Step 3 after you read the information in Step 8

Instructions for Prescribers

  • Fill out the Prescriber Information Sections in Steps 4-7.
  • Sign and date the PRESCRIBER/OFFICE MANAGER ATTESTATION at the end of Step 7B.
  • Required fields are marked with an asterisk.

Once a completed Enrollment Form is received, an IPSEN CARES Patient Access Specialist will  perform a benefits verification and review the patient’s coverage and out-of-pocket responsibility  with both the HCP and the patient typically within 1 business day. To learn more about IPSEN  CARES and support offerings, please call 866-435-5677, 8:00 am to 8:00 pm ET Monday through  Friday or visit www.ipsencares.com.

Required if patient is under 18 years of age.

Would you like to enroll in the Ipsen adherence text messaging program as outlined in Step 8, under Additional Product and Support Information?

Would you like to receive marketing information from Ipsen as described in Step 8, under Additional Product and Support Information?

Is Patient Insured? *
Does patient have secondary insurance?*
Is Physician a participating Provider?

Eligible patients using commercial insurance can save on out-of-pocket Ipsen medication costs. Please see Patient Eligibility & Terms and Conditions.

Patient Support

Would you like to request injection training for the parent/legal guardian if the patient is eligible?

Would you like to request HCP injection training from an IPSEN CARES nurse for your staff?

Has current prescription been sent to a Specialty Pharmacy? *

If you would like IPSEN CARES to triage the prescription to a Specialty Pharmacy, complete the Prescription information in Step 7A.

(Complete this section if you would like IPSEN CARES to triage the prescription to a Specialty Pharmacy)

PRESCRIPTION Increlex® (mecasermin) injection 10 mg/mL (40 mg per vial)
Select a weight-based initial dosage
kg weight
X
mg / kg
=
mg X 10
= Inject
BID
If well tolerated after 7 days
kg weight
X
mg / kg
=
mg X 10
= Inject
BID
If well tolerated after an additional 7 days
kg weight
X
mg / kg
=
mg X 10
= Inject
BID

Syringes for Injection *

*Dosing over 0.12 mg/kg BID has not been evaluated, and due to potential hypoglycemic effects, patients should not be dosed over 0.12 mg/kg BID. Route of Administration: INCRELEX is administered by subcutaneous injection. INCRELEX injections should be rotated to a different site (upper arm, thigh, buttock, or abdomen) with each injection to help prevent lipohypertrophy.

(The Prescriber must sign if this form is to be used as a prescription to be triaged to a Specialty Pharmacy, to request Injection Training, to enroll a patient for free goods as part of the Patient Assistance Program (PAP), or to enroll a patient for free goods as part of the Temporary Patient Assistance Program (TPAP). If the request is limited to Benefi Verification or Copay Assistance Support, the Prescriber, or an individual acting at the direction of the Prescriber and involved in the patient’s care, such as an Office Practice Manager, Financial Coordinator, Financial Counselor, Patient Assistance Coordinator, Patient Navigator, Social Worker, Insurance Coordinator, Patient Coordinator, or Patient Care Advocate, may sign this form.)

By signing below, I certify that the above therapy is medically necessary and that I have received the necessary authorization to release the information herein and medical and/ or patient information relating to INCRELEX® therapy to Ipsen and its agents or contractors for the purpose of seeking reimbursement for INCRELEX® therapy, assisting in initiating or continuing INCRELEX® therapy, and/or evaluating the patient’s eligibility for Ipsen’s patient support programs administered by IPSEN CARES. I authorize Ipsen to be my agent and to forward the above prescription, by fax or other mode of delivery, to the pharmacy chosen on behalf of the patient named on this form. For the state of New York, copies of all prescriptions should be on official New York state prescription forms. I certify that any medications received from Ipsen in connection with any IPSEN CARES program will be used only for the named patient. These medications will not be offered for sale, trade, or barter. Additionally, no claim for reimbursement will be submitted concerning any medications received from Ipsen, or any services provided by IPSEN CARES, to any payor, including Medicare, Medicaid, or any other federal or state health insurance program, nor will any medications be returned for credit. If the named patient does not return for therapy, product will be returned to Ipsen. I acknowledge that I have assisted the named patient in enrolling in IPSEN CARES exclusively for purposes of patient care and not in consideration for, expectation of, or actual receipt of remuneration of any sort.

I authorize my/the patient’s healthcare providers (including those pharmacies that may receive my/the patient’s prescription for INCRELEX®) to disclose personal health information (“PHI”) about me/the patient, including health information relating to my/the patient’s medical condition, prescription, and insurance coverage, to Ipsen Biopharmaceuticals, Inc., its affiliates, and its agents that have been hired to administer the Ipsen Coverage, Access, Reimbursement & Education Support (IPSEN CARES) program on its behalf (collectively, “Ipsen”) in order for Ipsen to: (1) enroll me/the patient in IPSEN CARES; (2) establish my/the patient’s benefit eligibility and potential out-of-pocket costs for INCRELEX®; (3) communicate with my/the patient’s healthcare providers and health plans about my/the patient’s treatment plan; (4) provide support services, including patient education and financial assistance for INCRELEX®; (5) help get INCRELEX® shipped to me/the patient; and (6) facilitate my/the patient’s participation in INCRELEX® patient programs as I have requested or may request. I agree that, using the contact information I provide, Ipsen may contact me for reasons related to the IPSEN CARES program and support services and may leave messages for me that may disclose that I am/ the patient is on INCRELEX® therapy. I consent to being contacted by an IPSEN CARES program representative in order for the program to obtain further information or clarification regarding any adverse event I/the patient may experience.

I understand that once my/the patient’s PHI has been disclosed to Ipsen, it is no longer protected by federal privacy laws and Ipsen may re-disclose it; however, Ipsen has agreed to protect my/the patient’s PHI by using and disclosing it only for the purposes described above or as required by law. I understand that my/the patient’s healthcare providers may receive remuneration from Ipsen in exchange for my/the patient’s PHI and/or for any therapy support services provided to me.

I can withdraw this authorization by calling IPSEN CARES at 1-866-435-5677 or mailing a letter requesting such revocation to IPSEN CARES, 11800 Weston Parkway, Cary, NC 27513, but it will not change any actions taken before I withdraw authorization. Withdrawal of authorization will end further uses and disclosures of PHI by the parties identified in this form except to the extent those uses, and disclosures have been made in reliance upon my authorization. I understand that I may refuse to sign this form and, if I do so, I/the patient will not be able to participate in IPSEN CARES programs, but it will not affect my/the patient’s eligibility to obtain medical treatment, my/the patient’s ability to seek payment for this treatment, or affect my/the patient’s insurance enrollment or eligibility for insurance coverage. This authorization expires three years from the date signed unless a shorter time is required by law or unless I revoke my authorization before that time. I understand that I will receive a copy of the signed authorization.

Additional Product And Support Information
Text Adherence Program

To the extent that I have opted in under step one of this form, I agree to be contacted by autodialed text messages (“texts”) at the mobile phone number I have provided below for the purpose of helping the patient stay on therapy, which may promote or advertise the Ipsen products included in the therapy plan. I certify that the number I am providing belongs to me and not a family member or other third party. I understand that I may opt out of individual communications of the program entirely at any time by calling 866-435-5677 or replying “STOP” by text to any text from Ipsen. Ipsen will not sell or rent this information and will use it only in accordance with this authorization and consent. Consent to being contacted by text messages is not a condition of participation in the IPSEN CARES programs or the purchase of any products or services. I understand that my cellular service carrier’s data and text messaging rates may apply. Privacy policy at www.ipsencares.com. This authorization expires three years from the date signed unless a shorter time is required by law or unless I revoke my authorization before that time. If I am pr oviding this consent on behalf of another person, I certify that I am authorized to agree to every element of this consent on behalf of such other person, and I agree that I will be liable and will hold Ipsen harmless in the event that such other person alleges that they did not give consent.

Marketing Information

To the extent that I have opted in under step one of this form, I would like to receive information from Ipsen via mail, email, phone or SMS/text, all of which may include marketing content, advertisements, disease state awareness materials and educational material about INCRELEX®, and programs that support patients. These text messages and voice calls may be made via the use of automatic telephone dialing systems. I certify that the number I am providing belongs to me and not to a family member or other third party. I understand that I do not have to sign this section of the form in order to participate in the IPSEN CARES program and that I may revoke this authorization to receive additional product information at any time. By signing below, I agree that Ipsen and its agents may use and disclose my personal information (including name, address, phone number, and/or email) to provide these services and Ipsen may also contact me to solicit my opinions regarding INCRELEX® and Ipsen’s products and services. I understand that my cell phone carrier’s standard rates may apply for calls to my cell phone. This authorization expires three years from the date signed unless a shorter time is required by law or unless I revoke my authorization before that time. I may revoke this authorization, by calling 866.435.5677 or sending a request in writing to: IPSEN CARES, 11800 Weston Parkway, Cary, NC 27513. If I am pr oviding this consent on behalf of another person, I certify that I am authorized to agree to every element of this consent on behalf of such other person, and I agree that I will be liable and will hold Ipsen harmless in the event that such other person alleges that they did not give consent.

©2021 Ipsen Biopharmaceuticals, Inc. All rights reserved. November 2021 MP-US-000563