Patient Authorization Statement
I authorize my healthcare providers, pharmacies and health insurers, and their service providers (“Providers”) to disclose information relating to my insurance benefits, medical condition, treatment and prescription details (“Personal Information”) to Novartis Pharmaceuticals Corporation, its affiliates and service providers (“Novartis”) and the Novartis Patient Assistance Foundation, Inc., and its service providers (“NPAF”) so they can provide the following support services (the “Services”):
- Help coordinate insurance coverage for, access to, and receipt of my medication.
- Communicate with me about possible financial assistance, including Novartis copay or NPAF programs, and, if I am enrolled, administer my participation in those programs.
- Communicate with me about my medication and treatment, including reminders, health and lifestyle tips, and product and other related information. Communications may be customized based on Personal Information obtained from my Providers.
- Conduct quality assurance and other internal business activities and ask for feedback related to the Services or my treatment.
In delivering the Services, Novartis and NPAF may share my Personal Information with each other, with my Providers, or with government agencies or other financial assistance programs that might help me pay for my medication. They may combine information collected from me with information collected from other sources and use that information to administer the Services. My pharmacies or other healthcare providers may receive payment from Novartis or NPAF for providing certain Services, such as medication or refill reminders, based on my enrollment or participation. Once I authorize disclosure of my Personal Information, it may no longer be protected by federal health privacy law and applicable state laws.
I understand I do not have to sign this Authorization to get my medication or insurance coverage, that I have a right to a copy, and can cancel this Authorization at any time by calling 1-855-537-4678 or writing to:PO Box 2971
850 Twin Rivers Dr
Columbus, OH, 43216-9532
orCustomer Interaction Center
Novartis Pharmaceuticals Corporation
One Health Plaza
East Hanover, NJ 07936-1080
This Authorization will expire 5 years after I sign it, or earlier if required by state law, unless I cancel it sooner. If I cancel it, I may no longer qualify for Services from Novartis or NPAF, but it will not impact my Provider’s treatment or my insurance benefits. I also understand that if a Provider is disclosing my Personal Information to Novartis or NPAF on an authorized, ongoing basis, my cancellation will be effective with respect to that Provider as soon as they receive notice of my cancellation. Cancellation will not affect prior uses or disclosures.
I agree for myself and certify (if applicable) that my caregiver agrees to receive non-marketing calls and texts from Novartis or NPAF, including through an autodialer or prerecorded voice, at the number(s) provided.
Terms and Conditions
Copay Limitations apply. Valid only for those with private insurance. The Program includes the copay card and Rebate, with a combined annual limit of $18,000. Patient is responsible for any costs once limit is reached in a calendar year. Program not valid (i) under Medicare, Medicaid, TRICARE, VA, DoD, or any other federal or state health care program, (ii) where patient is not using insurance coverage at all, (iii) where the patient's insurance plan reimburses for the entire cost of the drug, or (iv) where product is not covered by patient’s insurance. The value of this Program is exclusively for the benefit of patients and is intended to be credited toward patient out-of-pocket obligations and maximums, including applicable copayments, coinsurance, and deductibles. Program is not valid where prohibited by law. Patient may not seek reimbursement for the value received from this Program from other parties, including any health insurance program or plan, flexible spending account, or health care savings account. Patient is responsible for complying with any applicable limitations and requirements of their health plan related to the use of the Program. Valid only in the United States and Puerto Rico. This Program is not health insurance. Program may not be combined with any third-party rebate, coupon, or offer. Proof of purchase may be required. Novartis reserves the right to rescind, revoke, or amend the Program and discontinue support at any time without notice.
Bridge Program: Must have commercial insurance, a valid prescription for KESIMPTA, and a denial of insurance coverage based on a prior authorization requirement to qualify. Eligible patients may receive a monthly maintenance dose for up to 12 months or until insurance coverage approval, whichever occurs first. Not available to patients whose medications are reimbursed in whole or in part by Medicare, Medicaid, TRICARE, VA, DoD or any other federal or state program, or where prohibited by law. No purchase necessary. Program is not health insurance, nor is participation a guarantee of insurance coverage. Other limitations may apply. Novartis reserves the right to rescind, revoke or amend this Program without notice.
Novartis Consent to Receive Electronic Disclosures
From time to time, Novartis Pharmaceuticals Corporation (“we”, “us”, “our”, or “Company”) may be required by law to provide to you certain written notices or disclosures. Described below are the terms and conditions for providing to you such notices and disclosures electronically through your user account in various Novartis programs. Please read the information below carefully.
Getting paper copies
At any time, you may request from us a paper copy of any record provided or made available electronically to you by us. You may request delivery of such paper copies from us by following the procedure described below.
Withdrawing your consent
If you decide to receive notices and disclosures from us electronically, you may at any time change your mind and tell us that thereafter you want to receive required notices and disclosures only in paper format. How you must inform us of your decision to receive future notices and disclosure in paper format and withdraw your consent to receive notices and disclosures electronically is described below.
Consequences of changing your mind
If you elect to receive required notices and disclosures only in paper format, it will slow the speed at which we can complete certain steps in communications with you and delivering services to you because we will need first to send the required notices or disclosures to you in paper format, and then wait until we receive back from you your acknowledgment of your receipt of such paper notices or disclosures. To indicate to us that you are changing your mind, you must contact us as described below.
All notices and disclosures will be sent to you electronically
Unless you tell us otherwise in accordance with the procedures described herein, we will provide electronically to you all required notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to you during the course of our relationship with you. To reduce the chance of you inadvertently not receiving any notice or disclosure, we prefer to provide all of the required notices and disclosures to you by the same method and to the same address that you have given us. Thus, you can receive all the disclosures and notices electronically or in paper format through the paper mail delivery system. If you do not agree with this process, please let us know as described below. Please also see the paragraph immediately above that describes the consequences of your electing not to receive delivery of the notices and disclosures electronically from us.
How to contact Novartis Pharmaceuticals Corporation
You may contact us to let us know of your changes as to how we may contact you electronically, to request paper copies of certain information from us, and to withdraw your prior consent to receive notices and disclosures electronically as follows:
To advise Novartis Pharmaceuticals Corporation of your new email address
To let us know of a change in your email address where we should send notices and disclosures electronically to you, you must call us at 1-888-NOW-NOVA (1-888-669-6682) and state: your previous email address, your new email address. We do not require any other information from you to change your email address.
To request paper copies from Novartis Pharmaceuticals Corporation
To request delivery from us of paper copies of the notices and disclosures previously provided by us to you electronically, you must call us at 1-888-NOW-NOVA (1-888-669-6682) and state your email address, full name, US postal address, and telephone number.
To withdraw your consent with Novartis Pharmaceuticals Corporation
To inform us that you no longer want to receive future notices and disclosures in electronic format you may:
- Call us at 1-888-NOW-NOVA (1-888-669-6682) and state your email, full name, US postal address, telephone number, and account number. We do not need any other information from you to withdraw consent. The consequences of your withdrawing consent for online documents will be that transactions may take a longer time to process.
Required hardware and software:*
Operating Systems: Windows2000 or WindowsXP
Browsers (for SENDERS): Internet Explorer 6.0 or above
Browsers (for SIGNERS): Internet Explorer 6.0, Mozilla FireFox 1.0, NetScape 7.2 (or above)
Email: Access to a valid email account
Screen Resolution: 800 x 600 minimumEnable Security Settings:
- Allow per session cookies
- Users accessing the internet behind a Proxy Server must enable HTTP 1.1 settings via proxy connection
*These minimum requirements are subject to change. If these requirements change, we will provide you with an email message at the email address we have on file for you at that time providing you with the revised hardware and software requirements, at which time you will have the right to withdraw your consent.
Acknowledging your access and consent to receive materials electronically
To confirm to us that you can access this information electronically, which will be similar to other electronic notices and disclosures that we will provide to you, please verify that you were able to read this electronic disclosure by checking the appropriate box in the enrollment page.
By checking the “I Agree” box on the enrollment page, you confirm that:
- You can access and read this CONSENT TO RECEIVE ELECTRONIC DISCLOSURES document; and
- You can print on paper the disclosure or save or send the disclosure to a place where you can print it, for future reference and access; and
Until or unless you notify Novartis Pharmaceuticals Corporation as described above, you consent to receive from us exclusively through electronic means all notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to you by Novartis Pharmaceuticals Corporation during the course of your relationship with us.