PATIENT AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION
I authorize my healthcare providers and staff (together, “Healthcare Providers”), my health insurer, health plan, or programs that provide me healthcare benefits (together, “Health Insurers”), and any specialty pharmacies (“Specialty Pharmacies”) that dispense my medication to disclose to Regeneron Pharmaceuticals, Inc., Sanofi US, and their affiliates and agents (together, the “Alliance”) health information about me, including information related to my medical condition and treatment, health insurance coverage and claims, and prescription (including fill/refill information) related to my prescription for DUPIXENT® (dupilumab) therapy (“My Information”). I also authorize my Healthcare Providers, Health Insurers, Specialty Pharmacies and the Alliance to use My Information and share it with each other for the purposes described below. I understand that my Healthcare Providers, Health Insurers, Specialty Pharmacies and the Alliance will receive, use, and disclose My Information for the purposes of enrolling me in and providing certain services through the “DUPIXENT MyWay Program,” including:
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to determine if I am eligible to participate in DUPIXENT MyWay coverage assistance programs, patient assistance programs, or other support programs;
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to investigate my health insurance coverage for DUPIXENT injection;
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to obtain prior authorization for coverage;
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to assist with appeals of denied claims for coverage;
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for the operation and administration of the DUPIXENT MyWay Program;
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to communicate with me by mail, telephone, or email (or text message, if consented) regarding the Program, disease state and product-related education and services, information about my participation in the Program and treatment, and to evaluate and improve the Program and associated services provided, as set forth herein
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to refer me to, or to determine my eligibility for, other programs, or alternative sources of funding or coverage that may be available to provide assistance to me with the costs of my medication.
I understand that the Alliance may de-identify My Information and use it in performing research, education, business analytics, marketing studies, or for other commercial purposes, including linkage with other de-identified information the Alliance receives from other sources. I understand that members of the Alliance may share My Information, including identifiable health information, among themselves in order to de-identify it for these purposes and as needed to perform the Services or to communicate with me by mail, telephone, or email, or, if I indicate my agreement and consent herein, by text. I understand and agree that the Alliance may use My Information for these purposes and may share My Information with my Healthcare Providers, Health Insurers and Specialty Pharmacies.
I understand and agree that my Healthcare Providers, Health Insurers, and Specialty Pharmacies may receive remuneration from the Alliance in exchange for disclosing My Information to the Alliance and/or for providing me with support services in connection with the DUPIXENT MyWay Program.
Once My Information has been disclosed to the Alliance, I understand that federal privacy laws may no longer protect it from further disclosure. However, I also understand the Alliance has agreed to protect My Information by using and disclosing it only for the purposes allowed by me in this Authorization or as otherwise required by law.
I understand that I do not have to sign this Authorization. A decision by me not to sign this Authorization will not affect my ability to obtain medical treatment, payment for treatment, insurance coverage, access to health benefits or Alliance medications from covered entities such as Health Care Providers, Health Insurers, and Specialty Pharmacies. However, if I do not sign this Authorization, I understand that I will not be able to participate in the DUPIXENT MyWay Program.
I understand that this Authorization expires five years from the date of my signature or until my local state law requires expiration, subject to applicable law, unless and until I withdraw (take back) this Authorization before then, or as otherwise required by law. For patients with Maryland healthcare providers, this authorization expires 1 year from the date of signature. Further, I understand that I may withdraw this Authorization at any time by mailing or faxing a written request to DUPIXENT MyWay at 2730 S. Edmonds Lane, Suite 300, Lewisville, TX 75067; Fax: 1-844-387-9370. Withdrawal of this Authorization will end my participation in the DUPIXENT MyWay Program and will not affect any disclosure of My Information based on this Authorization made before my request is received and processed by my Healthcare Providers, Health Insurers, and Specialty Pharmacies. I understand that I may request a copy of this authorization.
PATIENT CONSENT AND CERTIFICATIONS DUPIXENT
MyWay Program Enrollment Consent. I am enrolling in the DUPIXENT MyWay Program (the “Program”) and authorize Regeneron Pharmaceuticals, Inc., Sanofi US, and their affiliates and agents (together the “Alliance”) to provide me services under the Program, as described in the Program Enrollment Form and as may be added in the future. Such services include medication and adherence communications and support, medication dispensing support, coverage and financial assistance support, disease and medication education, injection training, and other support services (the “Services”). If enrolling in the DUPIXENT MyWay Copay Card Program, I understand that Copay Card information will be sent to my designated specialty pharmacy along with my prescription, and any assistance with my applicable cost-sharing or copayment for DUPIXENT® (dupilumab) injection will be made in accordance with the Program terms and conditions.
Credit Check Consent. I authorize the Alliance to verify my eligibility for the DUPIXENT MyWay Patient Assistance Program, and I understand that such verification may include contacting me or my healthcare provider for additional information and/or reviewing additional financial, insurance, and/or medical information. I authorize the Alliance under the Fair Credit Reporting Act to use my demographic information to access reports on my individual credit history from consumer reporting agencies. I understand that, upon request, the Alliance will tell me whether an individual consumer report was requested and the name and address of the agency that furnished it. I further understand and authorize the Alliance to use any consumer reports about me and information collected from me, along with other information they obtain from public and other sources, to estimate my income in conjunction with the Patient Assistance Program eligibility determination process, if applicable.
Conditions of Participation. I further understand that no free product may be submitted for reimbursement to any payer, including Medicare and Medicaid; and no free product may be sold, traded, or distributed for sale. If approved for the DUPIXENT MyWay Patient Assistance Program, I will not seek to have the value of any medication provided to me under this program counted toward my true-out-of-pocket (TrOOP) cost for prescription drugs for my Medicare Part D Plan. Continuation in the DUPIXENT MyWay Patient Assistance Program is conditioned upon timely verification of income. In addition, I agree to notify DUPIXENT MyWay if my insurance situation changes.
Patients whose health insurance benefits offer, or whose health insurance plans work with, an alternative funding program are not eligible for the Alliance DUPIXENT MyWay Patient Assistance Program/need-based free drug. “Alternative funding programs” sometimes refer to themselves with different names and promote their services as a benefit being offered through patients’ health insurance plans. In determining whether your health insurance plan offers or works with an alternative funding program, please consider the following: (1) did a third party assist you with, or provide guidance about, the preparation of your application for this program and/or direct you to apply; (2) were you told that you were required to work with a third party or a “patient advocate” in order to receive coverage for your medicine; (3) were you told that you were required to apply to a manufacturer’s patient assistance program as a prerequisite to having plan coverage for your specialty drug, including Alliance products; (4) were you told that you do not have plan coverage for your specialty drug unless alternative funding sources for your specialty drug could not be found, (5) were you required by your plan to provide personal and health information to a third party program or enter such information into a third party patient portal in advance of completing this application, (6) did your employer recently tell you that your specialty drug plan benefits have changed; or (7) do you have any other reason to think that your health plan may work with an alternative funding program, or an alternative funding program may be involved in your plan benefits? If you answered yes to any of these questions, please check with your plan sponsor and review your plan benefits to determine whether your plan works with a third party that provides any of the services, or is connected to any of the requirements described herein. If it does, you are not eligible to apply for this program. By applying to the DUPIXENT MyWay Patient Assistance Program, you certify that the answer to all of these questions is “no.”
I also understand that the Services may be revised, changed, or terminated at any time and that the Program may be changed or discontinued without notice.
Communications Consent. I authorize the Alliance to communicate with me by mail, telephone, or email, or, if I indicate my agreement and consent above, by text, regarding the Program, disease state and product-related education and services, information about my participation in the Program and treatment, and to evaluate and improve the Program and associated services provided (together, the “Communications”). I understand that I may be contacted by the Alliance in the event that I report an adverse event. I understand that I do not have to enroll in the Program or receive the Communications, and that I can still receive DUPIXENT injection, as prescribed by my Healthcare Provider. I understand that Communications transmitted via unencrypted email or text message over an open network may be inherently unsecure, and there is no assurance of confidentiality for information communicated in this manner. I may opt out of receiving Communications, individual support services offered by the Program, including the DUPIXENT MyWay Copay Card, or opt out of the Program entirely at any time by notifying a Program representative by telephone at 1-844-387- 4936, by sending a letter to DUPIXENT MyWay 2730 S Edmonds Lane, Suite 300, Lewisville, TX 75067, or by contacting either Regeneron at DataProtection@Regeneron.com or Sanofi at PrivacyOfficeUSA@sanofi.com.
Use of Personal and Sensitive Information Consent. I understand that my health information, contact information, and other personal information I, my healthcare provider, and others share with Regeneron Pharmaceuticals, Inc., Sanofi US, and their affiliates and agents (together the “Alliance”) is collected to provide me with the assistance I request, for the purposes described in this Program Enrollment Form, and for other business purposes of the Alliance, as described in Regeneron’s Privacy Notice, available at regeneron.com/privacy-policy; Regeneron’s Consumer Health Data Privacy Policy, available at regeneron.com/privacy-policy; and Sanofi’s US Global Privacy Policy, available at sanofi.com/our-responsibility/sanofi-global-privacy-policy. Further, I understand that my consent is required to process my sensitive information under certain U.S. state privacy laws, and by signing herein, I consent to the collection, use, disclosure, and processing of my personal and sensitive information, including my personal health data as described in the Alliance’s privacy policies. I understand that I have the right to withdraw my consent at any time by notifying the Alliance using the contact information below. Depending on where I live, I may have certain rights with respect to my personal information, including the request to access or delete my personal information. I am aware that the Alliance may not be required to fulfill my requests in certain circumstances. I understand that to exercise these rights, I may contact Regeneron’s Privacy Office by emailing dataprotection@regeneron.com or by calling 1-844-835-4137 or Sanofi’s Privacy Office at PrivacyOfficeUSA@sanofi.com.
