Takeda Patient Support is a program that can help eligible patients prescribed a Takeda Hematology product with education and resources to help access their therapy and support them throughout their treatment journey.
By signing the Patient Authorization section of this Form, I authorize my physician, health insurance, and pharmacy providers (including any specialty pharmacy that receives my prescription) to disclose my protected health information, including, but not limited to, information relating to my medical condition, treatment, care management, and health insurance, as well as all information provided on this form (“Protected Health Information”), to Takeda Pharmaceuticals U.S.A., Inc. and its present or future affiliates, including the affiliates and service providers that work on Takeda’s behalf in connection with the Takeda Patient Support Program (the “Companies”). The Companies will use my Protected Health Information for the purpose of facilitating the provision of the Takeda Patient Support Program products, supplies, or services as selected by me or my physician and may include (but not be limited to) verification of insurance benefits and drug coverage, prior authorization support, financial assistance with co-pays, patient assistance programs, and other related programs. Specifically, I authorize the Companies to 1) receive, use, and disclose my Protected Health Information in order to enroll me in the Takeda Patient Support Program and contact me, and/or the person legally authorized to sign on my behalf, about the Takeda Patient Support Program; 2) provide me, and/or the person legally authorized to sign on my behalf, with educational materials, information, and services related to the Takeda Patient Support Program; 3) verify, investigate, and provide information about my coverage, including but not limited to communicating with my insurer, specialty pharmacies, and others involved in processing my pharmacy claims to verify my coverage; 4) coordinate prescription fulfillment; and 5) use my information to conduct internal analyses.
I understand that employees of the Companies only use my Protected Health Information for the purposes described herein, to administer the Takeda Patient Support Program or as otherwise required or allowed under the law, unless information that specifically identifies me is removed. Further, I understand that my healthcare provider may receive financial remuneration from Takeda Pharmaceuticals U.S.A. for marketing services. I understand that Protected Health Information disclosed under this Authorization may no longer be protected by federal privacy law. I understand that I am entitled to a copy of this Authorization. I understand that I may revoke this Authorization and that instructions for doing so are contained in Takeda’s Website Privacy Notice available at www.takeda.com/privacy-notice/ or I may revoke this Authorization at any time by sending written notice of revocation to the Takeda Patient Support Program, PO Box 2355, Morristown, NJ 07962. I understand that such revocation will not apply to any information already used or disclosed through this Authorization. This Authorization will expire at the earliest of what is required by state law, and never in any case longer than 5 years. I also understand that if I do not sign this Authorization, I will not be able to receive the Takeda Patient Support Program products, supplies, or services.
By signing below, I am electing to enroll in Takeda Patient Support for Hematology Services (“Services”) and direct all disclosures of my Information in connection with such Services (which may include, but are not limited to, verification of insurance benefits and drug coverage, prior authorization support, financial assistance with co-pays, patient assistance programs, alternate funding sources, other related programs, communication with me or my prescribing physician by mail, email, or telephone about my medical condition, treatment, care management, product information, and health insurance).
By agreeing to these Takeda Patient Support Program (the “Program”) text message terms and conditions, you agree to receive text messages on your mobile device subject to the Terms & Conditions described below. You also consent to receive autodialed and/or pre-recorded calls and/or text messages from or on behalf of the Program at the telephone number provided above. You understand that this consent is not a condition of purchase or use of the Program or of any Takeda product or service. You can unsubscribe from receiving text messages by texting STOP. You will remain enrolled in Takeda Patient Support. For questions about this Program, text HELP or contact the customer support center at 888-229-8379.
Participants will receive an average of 5 text messages each month while enrolled in the Program. Such messages may be nonmarketing messages related to the Patient Support Program.
There is no fee payable to Takeda to receive text messages; however, your carrier’s message and data rates may apply.
You represent that you are the account holder for the mobile telephone number(s) that you provide to opt into the Program. You are responsible for notifying Takeda immediately if you change your mobile telephone number. You may notify Takeda of a number change by calling 888-229-8379.
Data obtained from you in connection with your registration for, and use of, this SMS service may include your phone number and/or email address, related carrier information, and elements of pharmacy claim information and will be used to administer this Program and to provide Program benefits such as information about your prescription, refill reminders, as well as Program updates and alerts.
Takeda will not be liable for any delays in the receipt of any SMS messages as delivery is subject to effective transmission from your network operator.
This Program is valid with most major U.S. carriers, including Verizon Wireless, Sprint, Nextel, Boost Mobile, T-Mobile®, AT&T, Alltel, ACS Wireless, Bluegrass Cellular, Carolina West Wireless, CellCom, Cellular One of East Central Illinois (ECIT), Cincinnati Bell, Cricket, C-Spire Wireless, Duet IP (aka Max/Benton/Albany), Element Mobile, Epic Touch, GCI Communications, Golden State, Hawkeye (Chat Mobility), Hawkeye (NW Missouri Cellular), Illinois Valley Cellular (IVC), Inland Cellular, iWireless, Keystone Wireless (Immis/PC Management), MetroPCS, MobiPCS, Mosaic, MTPCS/Cellular One (Cellone Nation), Nex-Tech Wireless, nTelos, Panhandle Telecommunications, Pioneer, Plateau, Revol Wireless, Rina-Custer, Rina-All West, Rina-Cambridge Telecom Coop, Rina-Eagle Valley Comm, Rina-Farmers Mutual Telephone Co, Rina-Nucla Nutria Telephone Co, Rina-Silver Star, Rina-South Central Comm, Rina-Syringa, Rina-UBET, Rina-Manti, Simmetry, South Canaan/CellularOne of NEPA, Thumb Cellular, Union Wireless, United Wireless, U.S. Cellular, Viaero Wireless, Virgin Mobile, and West Central Wireless (includes Five Start Wireless). By agreeing to these Takeda Patient Support Program (the “Program”) text message terms and conditions, you agree to receive text messages on your mobile device subject to the Terms & Conditions described below. You also consent to receive autodialed and/or pre-recorded calls and/or text messages from or on behalf of the Program at the telephone number provided above. You understand that this consent is not a condition of purchase or use of the Program or of any Takeda product or service. You can unsubscribe from receiving text messages by texting STOP. You will remain enrolled in the Takeda Patient Support Program. For questions about this Program, text HELP or contact the customer support center at 888-229-8379.
Participants will receive an average of 5 text messages each month while enrolled in the Program. Such messages may be nonmarketing messages related to the Patient Support Program.
Takeda’s Co-pay Assistance Program (“the Program”) provides financial support for commercially insured patients who qualify for the Program. Participation in the Program and provision of financial support is subject to all Program terms and conditions, including but not limited to eligibility requirements, the Program maximum benefit per claim and the annual calendar year Program maximum (“Annual Program Maximum”). The Annual Program Maximum for your prescribed Takeda product can be found by visiting: https://www.takedapatientsupport.com/hematology.
By enrolling in the Program, you agree that the Program is intended solely for the benefit of you—not health plans and/or their partners. Further, you agree to comply with all applicable requirements of your health plan. The Program cannot be used if the patient is a beneficiary of, or any part of the prescription is covered by: 1) any federal, state, or government-funded healthcare program (Medicare, Medicare Advantage, Medicaid, TRICARE, etc.), including a state pharmaceutical assistance program (the Federal Employees Health Benefit (FEHB) Program is not a government-funded healthcare program for the purpose of this offer), 2) the Medicare Prescription Drug Program (Part D), or if the patient is currently in the coverage gap, or 3) insurance that is paying the entire cost of the prescription. No claim for reimbursement of the out-of-pocket expense amount covered by the Program shall be submitted to any third-party payer, whether public or private.
Some health plans have established programs referred to as ‘co-pay maximizer’ programs. A co-pay maximizer program is one in which the amount of a patient’s out-of-pocket costs is adjusted to reflect the availability of support offered by a manufacturer’s co-pay assistance program. If you are enrolled in a co-pay maximizer program, your Annual Program Maximum may vary over time to ensure the program funds are used for your benefit (for the benefit of the patient). Takeda also reserves the right to reduce or eliminate the co-pay assistance available to patients enrolled in an insurance plan that utilizes a co-pay maximizer program.
If you learn your health plan has implemented a co-pay maximizer program, you agree to notify the Program immediately by calling 1-888-229-8379. It may be possible that you are unaware whether you are subject to a co-pay maximizer program when you enroll or re-enroll in the Program. Takeda will monitor program utilization data and reserves the right to discontinue assistance under the Program at any time if Takeda determines that you are subject to a co-pay maximizer, or similar program.
The Program only applies in the United States, including Puerto Rico and other U.S. territories, and does not apply where prohibited by law, taxed, or restricted. This does not constitute health insurance. Void where use is prohibited by your insurance provider. If your insurance situation changes you must notify the Program immediately at 1-888-229-8379. Coverage of certain administration charges will not apply for patients residing in states where it is prohibited by law.
This Program offer is not transferable and is limited to one offer per person and may not be combined with any other coupon, discount, prescription savings card, rebate, free trial, patient assistance, co-pay maximizer, alternative funding program, copay accumulator, or other offer, including those from third parties and companies that help insurers or health plan manage costs. Not valid if reproduced.
By utilizing the Program, you hereby accept and agree to abide by these terms and conditions. Any individual or entity who enrolls or assists in the enrollment of a patient in the Program represents that the patient meets the eligibility criteria and other requirements described herein. You must meet the Program eligibility requirements every time you use the Program. Takeda reserves the right to rescind, revoke, or amend the Program at any time without notice, and other terms and conditions may apply.
Please review the information below and confirm accuracy before submitting.
You have enrolled into Takeda Patient Support for Hematology. While your application may not be eligible for the Co-pay Program, there are additional support services such as product access, educational resources and financial assistance that may be available to you. If you have questions, please contact Takeda Patient Support for Hematology at 1-888-229-8379.