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Patient Assistance Program
Enrollment Form
Abbreviations/Definitions
Adverse Events
BONUS
100

Where must you reside to be eligible for PAP Med D Renewal?

Must be a resident of the United States, the District of Columbia, Puerto Rico, Guam, or the U.S. Virgin Islands.

100

Name two things that is considered missing information on an application: 

  • Patients name
  • Patients dob 
  • Providers name 
  • Providers npi 
  • Major payer name 
  • Diagnosis code 
  • Providers signature
100

What does AE stand for?

Adverse Events

100

When should you report an AE?

24 hours

100

Name 5 pieces of PHI.

  • Names 
  • Geographic Subdivisions smaller than a state, such as a street addresses, city, county, precinct, and etc. 
  • DOB, Admission dates, discharge date, date of death, exact age 
  • Phone number 
  • Social security number 
  • Medical record #'s 
  • Fax # 
  • Health Plan Beneficiary # 
  • Email Addresses 
  • Account # 
  • Certificate & License # 
  • Vehicle Identifiers & Serial # including license plate # 
  • Device identifies & Serial # 
  • Web URLS 
  • Internet Protocols (IP) addresses 
  • Biometic Identifiers (Voice, finger, and retinal prints) 
  • Full face photos or images 
  • Any other unique #'s, characteristic, or code or prescription #'s
200

What is the income criteria for an annual adjusted household income?

Must have an annual adjusted household income of 151%-600% FPL

200

Is the weight on an enrollment for in pounds or kilograms?

Kilograms

200

What does PAPs stand for?

Patient Assistance Program

200

What is an Adverse Event?

an unfavorable or unintended sign, symptom or disease temporarily associated with the use of a medicinal product/device, whether or not related to the medicinal product/device.

200

Name 3 things that are considered Personal Information

  • Email Address 
  • Address 
  • Employee ID # 
  • Health Benefits Information 
  • Salary 
  • Benefits Enrollment  
  • Name 
  • Medical Leave
300

What are the 3 acceptable POIs?

1040 (tax return from 2023)
E-file form/W2s from 2023
60 days worth of paystubs

300

Are you able to obtain the prescription date and dose instructions verbally or written?

Written

300

Define PFS and PFP

Prefilled Syringe and Prefilled Pen

300

Is lack of efficiency considered an AE?

Yes.

400

What are the 4 types of support options offered by manufacturers?

Debit Card prepay model, Coupons or Vouchers, Claims Based, Retroactive

400

What diagnoses are Dupixent used to treat?

- Uncontrolled moderate-to-severe atopic dermatitis (AD)
- Prurigo nodularis (PN)
- Eosinophilic or oral corticosteroid–dependent asthma
- Chronic rhinosinusitis with nasal polyposis (CRSwNP)
- Eosinophilic esophagitis (EoE)

400

What does TPO stand for?

Treatment, Payment or Healthcare Operations

400

When emailing the manufacturer regarding a potential AE, how do you encrypt the email?

By typing "SECURE" as the first word in the email subject line.

500

What is the criteria for patients with Part D?

• Must have an active Medicare Part D plan, a valid PA, and express hardship

• Do not qualify for Extra Help (Medicare LIS)

• Proof of Extra Help denial required for Medicare patients whose income is ≤150% of the FPL^

• Annual gross household income ≤600% of the FPL^

500

What is one way you are able to submit missing information needed in order to process an application?

  • Submit it online via Document     Drop: https://www.patientsupportnow.org/patient/s/ (Patient Support Code: 8443879370) 
  • Fax it to: 1-844-387-9370 
  • Mail it to: PO Box 220128 Charlotte, NC 28222-0128
  • Sign the Enrollment Form electronically by calling 1-844-DUPIXEN(T) (1-844-387-4936) Option 1, Monday–Friday, 8 am–9 pm Eastern Time. A representative can help you complete the process in a few simple steps.
500

CRSwNP is the acronym for...

Chronic rhinosinusitis with nasal polyposis

500

What are the 6 pieces of information you need to report a potential AE?

1) Product Name
2) Reporter's First and Last Name
3) Reporter's Phone#
4) Patient's First and Last Name
5) Date of Potential AE
6) Description of Potential AE