WARNING: MALIGNANCIES AND SERIOUS INFECTIONS
Increased risk for developing serious infections and malignancies with ENVARSUS XR or other immunosuppressants that may lead to hospitalization or death

Adverse Events/Product Complaints | Please See Additional Important Safety Information Below
 

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Veloxis Transplant
Support Enrollment Form

Dedicated to helping patients and their physicians


Whether your patients have commercial or government insurance, or are uninsured/underinsured, we have dedicated financial support for patients on ENVARSUS XR. Available programs include:

30-day Free Trial*

Start your patient on ENVARSUS XR immediately, at no cost to the patient

$0 Co-pay

Out-of-pocket savings for eligible commercially insured patients

Patient Assistance Program (PAP)

Administered through Veloxis Transplant Support, provides free medication for eligible patients in need that meet Veloxis criteria. Please call your Financial Support Program Specialist to see if you qualify for Patient Assistance (free medication).

 

Patient Assistance Program Application Process

  • CALL 1-844-VELOXIS to Enroll
    A healthcare professional or patient calls 1-844-VELOXIS (835-6947) and selects the appropriate phone prompt for Veloxis Transplant Support (Dial 3). The phone prompt will direct the caller to a financial support representative who will review the process and guidelines for PAP eligibility. 

  • Complete the Veloxis Transplant Support Enrollment Form
    The applicant will be instructed to fill out and fax back the Veloxis Transplant Support Enrollment Form, available on www.EnvarsusXR.com, including the patient, insurance, and prescription information. The patient will be required to sign and date the form. The prescriber will be required to fill out and sign the prescription information (Section 5).*

    *Hard copy prescription required for the state of New York.

  • Veloxis Transplant Support will conduct a Benefits Investigation to determine patient eligibility
    Eligibility for PAP is determined on a per patient basis, so time to approval may vary. A 30-day free trial voucher is available for all patients, regardless of eligibility, who may require a longer Benefits Investigation.

  • Approved patients will receive an initial 60-day supply of medication and remain eligible for up to 1 year
    Accepted PAP patients are eligible for up to 1 year from notice of approval. All approved patients will be sent a 60-day supply of medication, which will be shipped directly to the patient or healthcare provider. A new Veloxis Transplant Support Enrollment Form is required for approved patients re-applying to the PAP after 1 year.

 

Providing Support 

Your Veloxis Transplant Support Specialist is your single point of contact to assist with:
 

Benefit Investigation

Verifying coverage, identifying possible restrictions, and reporting cost sharing by tier

Prior Authorization Assistance

Guiding you through every step of a payer’s process, identifying requirements, and providing templates for statements of medical necessity

Alternative Funding Research

Identifying independent foundations that can assist patients who are underinsured or uninsured

Coordination With Specialty Pharmacies

Ensuring access to ENVARSUS XR prior to filling prescriptions

Prescription Fulfillment Navigation

Identifying the most cost-effective method to fill ENVARSUS XR prescriptions

 

  • This voucher is good for cash-paying, Medicare, and Medicaid patients according to the following eligibility criteria and Terms of Use. No claim for reimbursement for product dispensed pursuant to this voucher may be submitted to ANY third-party payer, whether a commercial, private, or a government payer. This offer is not insurance and is not valid for mail order. Quantity limits may apply.
  • Eligible insured patients can save up to a maximum benefit of $3,000 annually off the patient’s co-pay or out-of-pocket expenses of ENVARSUS XR. Patient is responsible for any differential over $3,000. This offer can be used an unlimited number of times. Offer not valid for cash paying patients or where drug is not covered by the primary insurance. This offer is valid in the United States. No substitutions permitted. Offer not valid for prescriptions reimbursed under Medicaid, a Medicare drug benefit plan, Tricare, or other federal or state health programs (such as medical assistance programs).
  • Please call your Specialist to see if your patient will qualify for Patient Assistance (free medication). This offer is not insurance and is not valid for mail order. Quantity limits may apply.