An opportunity to make treatment more affordable for patients you have chosen to treat with Dysport
Ipsen is committed to assuring that every patient who can benefit from treatment with Dysport has the opportunity to do so.
What this Program does
Patients who qualify will receive a Dysport® Co-Pay Assistance Program Prepaid MasterCard® that can be used to help pay for their Dysport therapy. Use of this card is limited to your practice or to a specialty pharmacy. This program provides your eligible patients with up to $2000 of assistance ($500 per injection) for Dysport, the injection, and injection guidance, such as EMG. Patients can use their card to help with up to 4 treatments from October 1, 2011 to December 31, 2012.*
Which patients are eligible†
Patients treated with Dysport for cervical dystonia are eligible; patients are not eligible if they are being treated with Dysport for other conditions. Patients must be covered for Dysport by commercial insurance only. As with all co-pay card programs, Ipsen cannot offer this benefit to patients covered by government-funded insurance programs such as Medicare and Medicaid.
If you have questions about this Program, please:
Contact our Patient Access, Care, and Education (PACESM) team at 1-888-525-2423, 8:00 a.m. to 8:00 p.m. EST, Monday through Friday, and ask to speak with a Dysport Co-Pay Assistance Program Specialist.
How this Program works
Program Eligibility Guidelines
Patients may be eligible for the Dysport Co-Pay Assistance Program (“the Program”) if they are receiving Dysport for the treatment of cervical dystonia and their treatment is covered by a commercial insurance company. Eligible patients may receive up to $500 of assistance per Dysport injection with a maximum of $2000 in out-of-pocket assistance over a 12-month period. Patients will receive a debit card that can be used in the physician’s office or a specialty pharmacy (if applicable) to help cover their out-of-pocket costs.
Patients are not eligible for the Program if they:
- Are being treated with Dysport for any condition other than cervical dystonia
- Are uninsured for treatment with Dysport and are paying for Dysport therapy on their own
- Are covered by Medicare, Medicaid, TRICARE, the Department of Veterans Affairs or another federal- or state-funded program, or reside in the state of Massachusetts
- In addition, patients who reside in the states of Michigan, Rhode Island, and Minnesota will not be eligible for assistance with payment for authorized medical services as listed in the section below. Eligible patients residing in these states may only receive assistance with the cost of Dysport
Program Rules
By participating in the Dysport Co-Pay Assistance Program, I acknowledge and attest as follows:
- The patient identified on the form would otherwise be responsible for making the full co-pay or co-insurance amount due to the physician or specialty pharmacy
- The charge that the physician submits to a third party payer for drug cost must be separate from any charge for drug administration (injection and injection guidance). The Dysport Co-Pay Assistance Program will cover co-pay or co-insurance costs related to Dysport and authorized medical services (injection and injection guidance). No other treatment or office visit related expenses are covered by this Program. In the event that unauthorized charges are made to the card, the transaction(s) will be automatically reversed
- The patient is responsible for submitting an EOB form to the Dysport Co-Pay Assistance Program (with a detailed receipt from the specialty pharmacy if applicable) documenting actual eligible out-of-pocket expenses within 60 days of the patient’s Dysport injection. If an EOB form and any corresponding specialty pharmacy receipts (if applicable) are not received within 60 days of the patient’s injection, the charges to the card will be considered unauthorized and the transaction(s) will automatically be reversed. In that case, the patient will be responsible for making full payment to his/her physician or specialty pharmacy
- Participation in the Program is not inconsistent with any federal or state laws and regulations applicable to the physician’s practice, nor with any contracts or other agreements that the practice may have with third party payers
- The physician will disclose this patient’s use of the Program as required by the patient’s payer
- This Program may not be used for patients covered by any federal- or state-funded program or for patients residing in the state of Massachusetts. Patients who reside in the states of Rhode Island, Minnesota, and Michigan are not eligible for co-pay assistance for related medical services. Eligible patients in these states may only receive assistance for co-pay/co-insurance for the cost of drug
To download a copy of the Co-Pay Assistance Program healthcare professional brochure, click here.
To download a copy of the Co-Pay Assistance Program patient brochure, click here.
To download a copy of the PACE enrollment form, click here.
Note: Ipsen reserves the right to discontinue or amend the Dysport Co-Pay Assistance Program at any time.
*The maximum amount of co-pay assistance is $500 per injection, and will not exceed the patient’s actual out-of-pocket cost for Dysport, the injection, and injection guidance. Patients may receive a maximum of $2000 in assistance over a 12-month period. Patients must have commercial insurance coverage for Dysport.
†Patients covered by Medicare, Medicaid, TRICARE, the Department of Veterans Affairs, or other federal- or state-funded programs and residents of Massachusetts are not eligible for participation. Patients who reside in the states of Michigan, Rhode Island, and Minnesota will not be eligible for assistance with payment for injection- or injection guidance–related costs. Eligible patients residing in these states may only receive assistance for the cost of Dysport.
The Dysport® Co-Pay Assistance Program Prepaid MasterCard® is issued by The Bancorp Bank pursuant to license by MasterCard International and this card may not be used everywhere MasterCard is accepted. No cash or ATM access. MasterCard is a registered trademark of MasterCard International Incorporated. The Bancorp Bank; Member FDIC.
Indication
Dysport is an acetylcholine release inhibitor and a neuromuscular blocking agent indicated for the treatment of adults with cervical dystonia to reduce the severity of abnormal head position and neck pain in both toxin-naïve and previously treated patients.
Important Safety Information
Distant Spread of Toxin Effect: Postmarketing reports indicate that the effects of Dysport and all botulinum toxin products may spread from the area of injection to produce symptoms consistent with botulinum toxin effects. These may include asthenia, generalized muscle weakness, diplopia, blurred vision, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence, and breathing difficulties. These symptoms have been reported hours to weeks after injection. Swallowing and breathing difficulties can be life threatening, and there have been reports of death. The risk of symptoms is probably greatest in children treated for spasticity, but symptoms can also occur in adults treated for spasticity and other conditions, particularly in those patients who have underlying conditions that would predispose them to these symptoms. In unapproved uses, including spasticity in children and adults, and in approved indications, cases of spread of effect have been reported at doses comparable to those used to treat cervical dystonia and at lower doses.
Dysport is contraindicated in patients with hypersensitivity to any botulinum toxin product or its excipients, including human albumin, lactose, and cow's milk protein, or who have an infection at the proposed injection site.
The potency Units of Dysport are not interchangeable with other preparations of botulinum toxin products and, therefore, Units of biological activity of Dysport cannot be compared to or converted into Units of any other botulinum toxin products. Recommended dose and frequency of administration should not be exceeded.
Immediate medical attention may be required in cases of respiratory, speech, or swallowing difficulties. Dysphagia may persist for several weeks, and require use of a feeding tube to maintain adequate nutrition and hydration. Aspiration may result from severe dysphagia and is a particular risk when treating patients in whom swallowing or respiratory function is already compromised. Concomitant neuromuscular disorder may exacerbate clinical effects of treatment.
Individuals with peripheral motor neuropathic diseases, amyotrophic lateral sclerosis, or neuromuscular junction disorders should be monitored particularly closely when given botulinum toxin. Patients with neuromuscular disorders may be at increased risk of clinically significant effects, including severe dysphagia and respiratory compromise from typical doses of Dysport.
Dysport contains human albumin. Based on effective donor screening and product manufacturing processes, Dysport carries an extremely remote risk for transmission of viral diseases. A theoretical risk for transmission of Creutzfeldt-Jakob disease (CJD) also is considered extremely remote. No cases of transmission of viral diseases or CJD have ever been identified for albumin.
The possibility of an immune reaction when injected intradermally is unknown. The safety of Dysport for the treatment of hyperhidrosis has not been established.
Patients receiving concomitant treatment of Dysport and aminoglycosides or other agents interfering with neuromuscular transmission (e.g., curare-like agents), or muscle relaxants, should be observed closely because the effect of botulinum toxin may be potentiated. Use of anticholinergic drugs may potentiate systemic anticholinergic effects. The effect of administering different botulinum neurotoxins during the course of treatment with Dysport is unknown.
There are no adequate and well-controlled studies in pregnant women. Dysport should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
The most commonly observed adverse reactions (>5% of patients) with Dysport for the treatment of cervical dystonia are muscular weakness, dysphagia, dry mouth, injection site discomfort, fatigue, headache, neck pain, musculoskeletal pain, dysphonia, injection site pain, and eye disorders.
To report SUSPECTED ADVERSE REACTIONS or product complaints, contact Ipsen at 1-877-397-7671 (877- DYSPOR1). You may also report SUSPECTED ADVERSE REACTIONS to the FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
Please see full Prescribing Information, including Boxed Warning, and Medication Guide.
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