Patient Support for ONIVYDE® (irinotecan liposome injection)

Program Enrollment

Patients must be enrolled to access all IPSEN CARES^® support offerings.

Our Patient Access Specialists will check each patient’s pharmacy and medical benefits to determine if the drug is covered for the indication the treating physician has specified. If there are any restrictions, IPSEN CARES^® will provide the information required by the insurance company that the doctor may need to complete. A summary of all the information collected will be sent back to the doctor’s office in a single document, called Benefit Verification Results. Benefit verifications are usually turned around within 4 business hours^☨ upon receipt of the completed enrollment form and patient authorization.

Health care providers (HCPs) can help patients enroll in three ways:

Through our online provider portal
By printing a downloadable PDF to be filled out and faxed
By calling the Patient Access Specialists at IPSEN CARES^® at (866) 435-5677

HCPs, Log In to Submit

Online Patient Enrollment Form

HCPs, Download and Print

Patient Enrollment Form Spanish Patient Enrollment Form

Patients and Health Care Providers can also call IPSEN CARES^® at (866) 435-5677

Patient Authorization

Patients are required to sign the ONIVYDE^® Patient Authorization form every 12 months to give the Patient Access Specialists at IPSEN CARES^® permission to access the patient’s personal health information in order to help with getting started on treatment. The form can be signed and submitted online, or by downloadable PDF, which must be printed, filled out, signed, and faxed.

Sign and Submit

Online Patient Authorization Form

Or Download and Print

Patient Authorization Form

Help with Copays?

Check for copay coverage. Considering that some patients need financial assistance, our copay assistance programs may help eligible* patients with their treatment.

The ONIVYDE^® Copay Program for eligible, commercially insured patients is available by enrolling in IPSEN CARES^®. Here is the key information:

Patients pay $0 per order for ONIVYDE^® up to a maximum annual benefit
Copay assistance may be provided with up to a maximum annual benefit of $20,000 for the program year
For patients who have government-provided insurance (eg, Medicare, Medicaid, TRICARE) IPSEN CARES^® may be able to offer the contact information for independent nonprofit foundations that may be able to offer financial assistance

Parents/Caregivers, Download and Print

Copay Flashcard

*Patient Eligibility & Terms and Conditions: Patients are not eligible for copay assistance through IPSEN CARES^® if they are enrolled in any state or federally funded programs for which drug prescriptions or coverage could be paid in part or in full, including, but not limited to, Medicare Part B, Medicare Part D, Medicaid, Medigap, VA, DoD, or TRICARE (collectively, “Government Programs”), or where prohibited by law. Patients residing in Massachusetts, Minnesota, Michigan, or Rhode Island can only receive assistance with the cost of Ipsen products but not the cost of related medical services (injection). Patients receiving free starter therapy through the IPSEN CARES^® program are not eligible for the copay assistance program while they are waiting for insurance prescription coverage to begin. Patients receiving assistance through another assistance program or foundation, free trial, or other similar offer or program, also are not eligible for the copay assistance program during the current enrollment year.Cash-pay patients are eligible to participate. “Cash-pay” patients are defined for purposes of this program as patients without insurance coverage or who have commercial insurance that does not cover ONIVYDE^®. Medicare Part D enrollees who are in the prescription drug coverage gap (the “donut hole”) are not considered cash-pay patients, and are not eligible for copay assistance through IPSEN CARES^®. For patients with commercial insurance who are not considered to be cash-pay patients, the maximum copay benefit amount per prescription is an amount equal to the difference between the annual maximum copay benefit of $20,000 and the total amount of copay benefit provided to the patient in the ONIVYDE^® Copay Program for the 2019 calendar year. For cash-pay patients, the maximum copay benefit amount per prescription is $1,666.66, subject to the annual maximum of $20,000 in total. Patient pays any amount greater than the maximum copay savings amount per prescription.Patient or guardian is responsible for reporting receipt of copay savings benefit to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled through the program, as may be required. Additionally, patients may not submit any benefit provided by this program for reimbursement through a Flexible Spending Account, Health Savings Account, or Health Reimbursement Account. Ipsen reserves the right to rescind, revoke, or amend these offers without notice at any time. Ipsen and/or RxCrossroads by McKesson, are not responsible for any transactions processed under this program where Medicaid, Medicare, or Medigap payment in part or full has been applied. Data related to patient participation may be collected, analyzed, and shared with Ipsen for market research and other purposes related to assessing the program. Data shared with Ipsen will be de-identified, meaning it will not identify the patient. Void outside of the United States and its territories or where prohibited by law, taxed, or restricted. This program is not health insurance. No other purchase is necessary. Offer expires December 31, 2019.^☨Data on file, IPSEN CARES Statistics – 1/2014-12/2018. Basking Ridge, NJ: Ipsen Biopharmaceuticals, Inc; 2018.

Free Medication

Uninsured patients may be eligible for free medication through our Patient Assistance Program. To qualify, patients must be: 1) uninsured, 2) US residents, and 3) meet income criteria.

HCPs, Log In to Submit

Online Patient Assistance Program Application

Or Patients, Download and Print

Patient Assistance Program Application

Patient support for those prescribed ONIVYDE^®.

BELOW IS ANOTHER WAY WE CAN PROVIDE ASSISTANCE

For product information, go to ONIVYDE.com/for-patients

Need immediate assistance?Call (866) 435-5677.

Patient support for those prescribed ONIVYDE®.

BELOW IS ANOTHER WAY WE CAN PROVIDE ASSISTANCE

For product information, go to ONIVYDE.com/for-patients

Need immediate assistance?Call (866) 435-5677.

Leaving Website

Patient support for those prescribed ONIVYDE^®.