Dysport® Ordering and Support
An easy ordering process with several options
WAYS TO ORDER
500-Units Vial
NDC 15054-0500-01*
300-Units Vial
NDC 15054-0530-06*
Each box contains 1 sterile, single-use vial with accompanying Full Prescribing Information and Medication Guide.
To help you order Dysport quickly and easily:
If you practice within an institution please acquire Dysport from your wholesalers
For Private Practice/Clinic, click HERE
Note: For billing purposes, the NDC number requires 11 digits. Therefore, a zero must be entered into the 10th position (eg, “15054-0500-01”). This is consistent with Red Book and First Databank listings.
HOW TO IDENTIFY
How to identify authentic Dysport for therapeutic uses
The best way to ensure your patients are receiving authentic Dysport is to order from an authorized Dysport distributor. See below for the various things you can check on each Dysport package to make sure it is authentic. There are more anti-counterfeiting measures on the packaging that aren’t listed here. Ask your distributor for more information.
300 units/vial
500 units/vial
IPSEN CARESTM Provides Support for Patients and Providers
The IPSEN CARES Patient Access Specialists are fully dedicated to:
- Facilitating patients’ access to their prescribed medications
- Providing information and support for interactions among offices, patients, and insurance companies for Ipsen medications
IPSEN CARES provides a single point-of-contact dedicated to assisting patients, providers, and staff.
Phone: 1-866-435-5677
Fax: 1-866-525-2416
Hours: Monday–Friday 8:00 am–8:00 pm ET
Website: www.ipsencares.com
REIMBURSEMENT ASSISTANCE
- Benefits Verification – verifies patients’ coverage, restrictions (if applicable), and copay/coinsurance amounts
- Prior Authorization (PA)/Appeals
- Provides information on documentation required by payers on PA specifics, and recommendations for next steps based on payer policy
- Provides information on the payer-specific processes required to submit a level I or a level II appeal, and guidance as needed throughout the process
FINANCIAL SUPPORT
- Copay Assistance – offers copay assistance to eligible* patients. This includes referring to the Dysport Commercial Copay Program or referring to an independent nonprofit organization if available
- Patient Assistance Program (PAP) – determines patients’ eligibility** for PAP and dispenses free product to eligible patients
PRODUCT DISTRIBUTION
- Institutions – Dysport can be acquired from wholesaler
- Private practices
- Direct (buy-and-bill) acquisition from a group of approved specialty distributors
- Specialty pharmacy delivery (IPSEN CARES can provide helpful information on selection of the appropriate specialty pharmacy for the patient by calling (1-866-435-5677)
PATIENT SUPPORT
- 360° Communication – conducts calls to both healthcare provider and patient with status updates about patient’s IPSEN CARES enrollment, benefits verification results, coverage status, dispense date, etc.
HCP ONLINE PORTAL
Ipsen realizes that more work is now being done by computer rather than paper and fax machines.We hope this online portal will be a convenient resource for you and your office. After you register and create a profile, your profile will be validated within 1 business day.
Through the online portal you can:
- Submit enrollments and check their status
- Download additional forms and materials
- Send a message to the IPSEN CARES team
- Obtain specialty pharmacy dispensing information (if applicable)
Visit www.ipsencares.com/hcp-resources to learn more.
Dysport Copay Assistance Program
Assistance with Private Insurance Copay or Coinsurance Costs for Dysport
EASE PATIENTS’ OUT-OF-POCKET COSTS FOR DYSPORT
- Eligible* patients can pay as little as $0 per prescription. Annual maximum of $5,000 per calendar year in copay assistance
- Program exhausts after 4 injection treatments, or a maximum annual copay benefit of $5,000, whichever comes first
- Program resets every January 1
- IPSEN CARES will confirm with patient on an annual basis that they still meet criteria for program
SIMPLE STEPS FOR PATIENTS TO RECEIVE THEIR DYSPORT ASSISTANCE
- Provider and patient complete Enrollment Form and send to IPSEN CARES
- Patient is administered Dysport
- Provider submits claim to patient’s insurance company
- Once claim is paid, provider submits the following documents via fax (253-395-8028)
- Completed CMS-1500 or CMS-1450 form
- Explanation of benefits (EOB)/remittance from the patient’s primary private insurance showing itemized allowed charges and remaining cost share for the Dysport therapy
- IPSEN CARES processes eligible claim payment to patient’s provider typically within 7–10 business days via either ACH (wire transfer) or check
Patient Authorization Form
Once a patient is enrolled in IPSEN CARES, a Patient Authorization Form needs to be completed by the Patient/Legal Guardian every 3 years* in order to maintain participation in IPSEN CARES. The form needs to be printed, filled out completely by the Patient/Legal Guardian, signed, and faxed back to IPSEN CARES. It is important that the Patient/Legal Guardian review the original IPSEN CARES Enrollment Form prior to signing the Authorization Form.
*NOTE: The patient authorization will expire sooner than 3 years where required by state law.
Patient Assistance Program (PAP) Application
The Patient Assistance Program (PAP) is designed to provide Dysport at no cost to eligible patients. Patients may be eligible to receive free drug if they are experiencing financial hardship, are uninsured or functionally uninsured, are a U.S. resident, and received a prescription for a use indicated in the approved label of Dysport, as supported by information provided in the program application. Eligibility does not guarantee approval for participation in the program. The PAP provides Dysport product only, and does not cover the cost of previously purchased product or medical services.
*Patient Eligibility & Terms and Conditions: Patients are not eligible for copay assistance through IPSEN CARES if they are enrolled in any state or federally funded programs for which drug prescriptions or coverage could be paid in part or in full, including, but not limited to, Medicare Part B, Medicare Part D, Medicaid, Medigap, VA, DoD, or TRICARE (collectively, “Government Programs”), or where prohibited by law. Patients residing in Massachusetts, Minnesota, Michigan, or Rhode Island can only receive assistance with the cost of Ipsen products but not the cost of related medical services (injection). Patients receiving assistance through another assistance program or foundation, free trial, or other similar offer or program, are not eligible for the copay assistance program during the current enrollment year.
Cash-pay patients are eligible to participate. “Cash-pay” patients are defined for purposes of this program as patients without insurance coverage or who have commercial insurance that does not cover Dysport. Medicare Part D enrollees who are in the prescription drug coverage gap (the “donut hole”) are not considered cash-pay patients and are not eligible for copay assistance through IPSEN CARES. For patients with commercial insurance who are not considered to be cash-pay patients, the maximum copay benefit amount per prescription is an amount equal to the difference between the annual maximum copay benefit of $5,000 and the total amount of copay benefit provided to the patient in the Dysport Copay Program. In any calendar year commencing January 1, the maximum copay benefit amount paid by Ipsen Biopharmaceuticals, Inc. will be $5,000, covering no more than four (4) Dysport treatments. For cash-pay patients, the maximum copay benefit amount per eligible Dysport treatment is $1,250, subject to the annual maximum of $5,000 in total. There could be additional financial responsibility depending on the patient’s insurance plan.
Patient or guardian is responsible for reporting receipt of copay savings benefit to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled through the program, as may be required. Additionally, patients may not submit any benefit provided by this program for reimbursement through a Flexible Spending Account, Health Savings Account, or Health Reimbursement Account. Ipsen reserves the right to rescind, revoke, or amend these offers without notice at any time. Ipsen and/or RxCrossroads by McKesson are not responsible for any transactions processed under this program where Medicaid, Medicare, or Medigap payment in part or full has been applied. Data related to patient participation may be collected, analyzed, and shared with Ipsen for market research and other purposes related to assessing the program. Data shared with Ipsen will be de-identified, meaning it will not identify the patient. Void outside of the United States and its territories or where prohibited by law, taxed, or restricted. This program is not health insurance. No other purchase is necessary.
**Patients may be eligible to receive free drug if they are experiencing financial hardship, are uninsured or functionally
uninsured, are US residents, and received a prescription for a use indicated in the approved label of Dysport, as supported by information provided in the program application. Eligibility does not guarantee approval for participation in the program. The PAP provides Dysport product only, and does not cover the cost of previously purchased product or medical services.
