Show:
QUICK START/BRIDGE
COPAY CARD
PAP
BUSINESS RULES
BUSINESS RULES #2
100

What is the day supply for Epizyme Quick Start and Bridge?

15 days at a time. Can be renewable one time only not to exceed 2 shipments. 

***if additional supply is needed approval needs to be sought after***

100

What is the annual cap for the program and what is the patients monthly copayment after copay card is applied?

$20,000 annual cap

$0 monthly copayment

100

What is the FPL for Epizyme and how is FPL determined?

Epizyme FPL is 550%

This is determined based off of household size and patient income.

100

Who dispenses Tazverik free good products?

Caremed is the dispensing pharmacy for any PAP, QS, Bridge supply.

100

Every profile has a pop up. What information will be applied to that section of the profile for EpizymeNow?

Start Date- when patient started or will start therapy

Anti-Emetic- Nausea medication (Zofran, Zyprexa, Compazine etc)

Off-label, IOD, Consumer notification (state depending) if needed

Free good approval

200

When will a patient qualify for a Quick Start or Bridge?

Patient must have an on-label diagnosis code (DX) and be enrolled in a commercial plan.

Patients with a government payor (Medicare, Medicaid, TriCare) are unable to received these services

200

What type of patient can qualify for copay card?

A commercial patient on or off-label is able to qualify for a copay card.

***note that a patient who is enrolled in Medicare A and B, Caremark Federal or has any type of government medical and or prescription coverage is not eligible for a copay card***

200
What is needed to submit for PAP?

LOMN/CLINICALS- ALWAYS

INCOME DOCS- ALWAYS

PATHOLOGY- ES (C49) ONLY

FHL- OVER INCOME (APPEAL PT)

2 COVERAGE DENIALS- IF INS REJECTS CLAIM

200

Tazverik is an LDD medication. What pharmacy is able to dispense the product?

SP- ONCO360 (only)

IOD- (In Office Dispensing) site

200

What programs do EpizymeNow offer to patients?

Quick Start- 15 day supply plus 1 refill (new to start)

Bridge- 15 day supply plus 1 refill (already on therapy)

PAP- 30 day supply for financial or ins denial reasons, no ins

EZH2- A test that Quest Diagnostic offers to check on this specific mutation (MRN 200359)

***note EZH2 is handled by Quest Diagnostic and not HUB***

300
When would a patient qualify for a Bridge vs Quick Start?

A Bridge supply is give to a patient when they are currently on therapy and there is delay in obtaining the next fill. 

example- PA (prior authorization) needs to be reinitiated, insurance change, foundation exhausted and enrolling into a new one, LDD override.

A Quick Start is for a new start of therapy and there is a current delay in patient getting started

example- PA (prior authorization) is being submitted or pending determination, LDD override, foundation delay, cost exceeds maximum override

300
When a request for assistance billing the copay card is needed who gets contacted?
The caller should be directed to Trial Card 866-420-7703
300
If a patient does not have ES or FL what type of PAP request would be written?
None, due to patient being off-label we are not able to service PAP for these patients unless they have been previously approved and are already grandfathered in.
300

What are the 3 bucket types and when are they utilized?

No Insurance- patient does not have any prescription drug coverage


Financial- patient insurance covers the cost of the medication but is unable to afford the copayment and no other assistance is available (copay card, foundation etc)

PA Denied- the plan for whatever reason is not allowing the claim to go through and 2 coverage denials are on file (can be more or less on a case by case basis)

300

When a patient is approved for Patient Assistance how long is the patient enrolled into the program?

PAP patients are approved until the end of the calendar year (12/31). A Medicare or Medicaid patient that has been dispensed at least 1x is automatically locked in and can not be removed. 


A commercial patient even though approved until 12/31 can be removed at any time if claim becomes affordable. 


A uninsured patient is approved until 12/31 but is considered a month to month approval and patient can be removed if insurance is obtained
400

We have a patient who is currently on therapy. The patient changed insurances through their spouse's job. The patient has been on therapy for 6 months and paying a copay of $65. The patient has a dx code of C71.9. The patient has been out of therapy for 7 days. Would this patient be able to obtain a Quick Start or Bridge supply? 

Due to the patient being off-label the patient would not qualify for either a Quick Start or Bridge.

400

If the patient is in need of assistance after the copay card is exhausted and the patient is off-label what services can we offer?

Due to the manufacturer changing the business rules to not allow PAP for off-label patients. A copay card exception would be the only way we could assist the patient before the copay resets come the first of the year. 

400
When PAP is approved for a patient what is the day supply that a patient is dispensed?

Patients are given a 30 day supply of medication at a time. Unless approved by the MFG.

400

What is the program name, hours, phone number, fax numbers, ext?

EpizymeNow (Epi-Zime-Now)

Program hours- 9am-6pm EST

Phone number- 833-437-4669

Fax number- 833-437-1437 (PEF)

Fax number- 978-313-0860 (Refills)

EXT- 9247

400

When is PAP approval notification sent to the mdo?

PAP approval notification is sent to mdo upon setting up first PAP dispense.

500
A patient with an dx code of C49.9 with commercial insurance is currently in need of an appeal. the office has submitted and it is currently pending determination. The patient is needing to start in 48 hours, however the patient is currently on a business trip in Guam and currently working on getting home. Would this patient qualify for a quick start or Bridge at this time?
Yes, the patient would qualify a Quick start as they are new to start and has commercial coverage. The patient is currently in a US Territory which does not change their eligibility and allows them to qualify for Quick Start.


***note if patient was in a non US Territory the patient would need to be in a US Territory before we can ship the package***

 
500

What is the purpose of a copay card for Tazverik?

The copay card allows the patient to get assistance as a commercially insured patient with their copayment.

500

When submitting a PAP request who approves the requests when the HUB submits.

Manny and Jakor approve requests for under 550% FPL

Manny and Jakor submit the requests to Adam and he will forward it to the committee if over 550% FPL.

***note if its an appeal case (over 550% FPL) there is no tat for the committee to render a decision***

500

What must be on file to proceed with patient case? How do we obtain this if it is not sent over?

Patient consent must be on file before proceeding with the case. Without consent we are unable to run a BV (benefit verification) and proceed with patient case.


Consent can be obtained by signing the PEF (patient enrollment form), Docusign and E-Consent (not active yet but coming)

500

What makes a patient off label?

A patient is off-label if their dx code does not begin with C82 (FL) or C49 (ES)

***On Label DX codes can be found in the shared folder under Tazverik Training Docs***