PATIENT ASSISTANCE PROGRAMS

(1)

PATIENT ASSISTANCE PROGRAMS

Definitions

BCCA BC Cancer Agency

SAP Health Canada Special Access Program

Class I Reimbursed for active cancer or approved treatment or approved indication only

Class II Reimbursed for approved indications only. Completion of Class II Approval Form is necessary. In addition, where indicated, approval from Tumour Group Chair or delegate is required for reimbursement

Restricted Funding Reimbursement for approved indications only. Completion of the BCCA Compassionate Access Program Application (formerly Undesignated Indication Form) is necessary to provide the appropriate clinical information for each patient

Home injection programs

The Patient Assistance Program chart is a general reference on the available programs offered by pharmaceutical manufacturers to help patients access specific drug therapies. Inclusion in the chart does not imply BC Cancer Agency endorsement of any drug therapy that is not approved on the BC Cancer Agency Benefit Drug List. Care has been taken to ensure accuracy of information; however it is not intended to replace specific information as provided by the manufacturer. Since program requirements are constantly evolving, it is advised that this chart not be used as a sole source of information.

DRUG SUPPLIER BCCA CLASS PROGRAM INFORMATION PHARMACARE

SPECIAL AUTHORITY Buserelin

(SUPREFACT®)

Sanofi-Aventis Class I SUPREFACT® Home Injection Program Medicum Patient Assistance Program Tel: 1-877-787-3228

Fax: 1-877-787-3376 Assistance offered:

 Home delivery (weigh bills provided to

pharmacies to ship buserelin and charge to the SUPREFACT® Community Care and Home Injection Program)

 Home injection service (free of charge)

Not required

(2)

SPECIAL AUTHORITY Degarelix

(FIRMAGON®)

Ferring Class I FIRMAGON® Care Program

Tel: 1-866-872-5772 Fax: 1-877-722-2730 Assistance offered:

pharmacies to ship degarelix and charge to the FIRMAGON® Care Program)

 Home injection service (free of charge) for non- ambulatory patients near major centers (case- by-case basis in remote regions)

Not required

Goserelin (ZOLADEX®)

Astra-Zeneca Class I ZOLADEX® Community Care and Home Injection Program

pharmacies to ship goserelin and charge to the ZOLADEX® Community Care and Home Injection Program) free of charge

Not required

Leuprolide (ELIGARD®)

Sanofi-Aventis Class I ELIGARD® Home Injection Program Tel: 1-877-787-3228

pharmacies to ship leuprolide and charge to the ELIGARD® Community Care and Home Injection Program)

Not required

Leuprolide (LUPRON®)

TAP

Pharmaceuticals

Class I LUPRON® Comfort Program Tel: 1-866-958-7766

 Help for patients to obtain third party coverage

 Financial assistance may be provided

Not required

(3)

SPECIAL AUTHORITY Octreotide

(SANDOSTATIN®)

Novartis

Pharmaceuticals

Class I Access SANDOSTATIN® LAR Tel: 1-866-281-4688

 Help for patients to obtain third party coverage

 Financial assistance may be provided

Not required

(4)

Supportive care medications

SPECIAL AUTHORITY Aprepitant

(EMEND®)

Merck Funded by

BCCA for approved indications for inpatient use only.

Merck Canada Patient Assistance Program®

 Compassionate supply is available to patients without third party insurance coverage

 Once certain criteria are met (i.e. proof of low income) medication is delivered to prescriber’s office or to a designated pharmacy to dispense and for patient pick up

PharmaCare Special Authority required.

Please fax form General Special Authority Request to PharmaCare

Fax: 1-800-609-4884

Dalteparin (FRAGMIN®)

Pfizer Funded by

Fragmin® SmartSample Program Tel: 1-800-563-3274

Assistance offered:

 Once prescribed by the physician, the physician will:

o Apply for PharmaCare Special Authority o Give the patient a SmartSample® card

 The SmartSample® card entitles the patient to a few free dalteparin pre-filled syringes from a community pharmacy for use while waiting for PharmaCare approval

o treatment doses (5 free syringes) o prophylactic doses (10 free syringes)

PharmaCare Special Authority required.

Please fax form Venous Thromboembolic Disease to PharmaCare

Fax: 1-800-609-4884

Darbepoetin (ARANESP®)

Amgen Not funded by BCCA

VICTORY® Program Tel: 1-888-706-4717 Fax: 1-888-987-2201 Assistance offered:

 Financial assistance is available to all patients who have third party insurance coverage but may need help with the co-pay

 Darbepoetin will be shipped by Victory program to a designated pharmacy

Not required

(5)

DRUG SUPPLIER BCCA CLASS PROGRAM INFORMATION PHARMACARE SPECIAL AUTHORITY Eltrombopag

(REVOLADE®)

GlaxoSmithKline Not funded by BCCA

inReach Patient Support Program Tel: 1-888-475-4255

 Financial assistance is available to patients with or without third party insurance. Patients may be asked to co-pay based on household income.

Not required

Epoetin Alfa (EPREX®)

Janssen Not funded by BCCA

SPECTRUM Support Program for Eprex®

 A compassionate supply is available to patients without third party insurance coverage, based on financial needs

 SPECTRUM program coordinates delivery with patients preferred pharmacy

 Initial self injection training with Nurse available in most regions. SPECTRUM program will coordinate nurse home visit with patient

Not required

Filgrastim (NEUPOGEN®)

Amgen Funded by

 Victory® Program will assist with the co-pay based on financial need and Fair PharmaCare deductible for each patient

 Compassionate supply will be shipped by Victory®

program to a designated pharmacy.

 Program to be initiated and PharmaCare approval established before patient goes to the pharmacy

PharmaCare Special Authority required prior to program being initiated.

Please fax form Filgrastim (GCSF) to PharmaCare

Fax: 1-800-609-4884

(6)

DRUG SUPPLIER BCCA CLASS PROGRAM INFORMATION PHARMACARE SPECIAL AUTHORITY Pegfilgrastim

(NEULASTA®)

 Compassionate supply will be shipped by Victory®

program to a designated pharmacy

 If patient is prescribed NEULASTA® and has no third party coverage, they will be offered

NEUPOGEN®

 Program to be initiated before patient goes to pharmacy

Not required

Valacyclovir (VALTREX®)

VALTREX® Patient Assist Program Tel: 1-844-794-3577

Web: https://www.rxhelp.ca/Valtrex Assistance offered:

 The VALTREX® Patient Assist Program will cover up to the difference between the out of pocket amount of branded VALTREX® (valacyclovir hydrochloride) versus the out of pocket amount a patient would have paid based on the average generic drug price.

 This amount will vary depending on each patient’s coverage (i.e., public, private, none) in each province.

 Patients must first have their prescription filled at a community pharmacy and have the receipt when they call the program

Not required

(7)

Drugs with assistance/reimbursement programs and/or coordination of insurance coverage

SPECIAL AUTHORITY Abiraterone

(ZYTIGA®)

Janssen Restricted Funding

ZYTIGA® Access Program (ZAP) Tel: 1-855-998-4423

 Financial assistance is available to all patients with or without third party insurance

 No compassionate supply available

 Home delivery available through McKesson Pharmacy

 Home delivery of one blood pressure monitor per patient available

Not required

Afatinib (GIOTRIF®)

Boehringer Ingelheim

Restricted Funding

HeadStart Patient Assistance Program Tel: 1-800-987-9080

 Financial assistance is available to all patients with or without third party insurance

 Compassionate supply available

 Home delivery available through BioScript Pharmacy

 Program information can be found at:

www.BIHeadStart.ca

Not required

Axitinib (INLYTA®)

Pfizer Restricted Funding

Pfizer Oncology Reimbursement Assistance Program - Inlyta®

 Financial assistance is available to eligible patients with third party insurance coverage but may need help with the co-pay

Not required

(8)

DRUG SUPPLIER BCCA CLASS PROGRAM INFORMATION PHARMACARE SPECIAL AUTHORITY Bevacizumab

(AVASTIN®)

Roche Class II or Restricted Funding based on indication

Roche Patient Assistance Program Tel: 1-888-748-8926

 Financial assistance is available to all patients with third party insurance coverage but may need help with the co- pay

 Infusion coordination provided if required

Not required

Bendamustine (TREANDA®)

Lundbeck Restricted Funding

TREANDA® Patient Support Program Tel: 1-855-489-6576

 No compassionate supply available

Not required

Bosutinib (BOSULIF®)

Pfizer Not funded by BCCA

BOSULIF® First Resource Program Tel: 1-888-963-4778

 Financial assistance is available to patients with or without third party insurance

 Compassionate supply may be available

 Assistance offered until September 3, 2015

Not required

Capecitabine (XELODA®)

Not required

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DRUG SUPPLIER BCCA CLASS PROGRAM INFORMATION PHARMACARE SPECIAL AUTHORITY Ceritinib

(ZYKADIA®)

Novartis Not funded by BCCA

My Lungs Program Tel: 1-855-489-4362 Fax: 1-855-788-3159 Assistance offered:

 Financial assistance is available to all patients who have third party insurance coverage but may need help with the co-pay

 Patients who were previously enrolled in the

compassionate use program will get financial assistance with no limit. New patients will get 20% financial

assistance.

 Home delivery available through McKesson Pharmacy

Not required

Crizotinib (XALKORI®)

Pfizer Restricted Funding

XALKORI® Reimbursement Support Program First Resource Program (Medicum)

 Financial assistance is available to all patients who have third party insurance coverage but may need help with the co-pay

 Crizotinib will only be provided to patients who have tested ALK-positive using a validated ALK assay at a laboratory with demonstrated proficiency in the specific technology

 Program does not coordinate or cover cost of ALK testing

Not required

Dabrafenib (TAFINLAR®)

 Financial assistance is available to patients with or without third party insurance. Patients may be asked to co-pay based on household income.

 Patient must be BRAF-positive

 Program does not coordinate or cover cost of BRAF testing

 Home delivery available through BioScript Pharmacy

Not required

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DRUG SUPPLIER BCCA CLASS PROGRAM INFORMATION PHARMACARE SPECIAL AUTHORITY Denosumab

(XGEVA®)

Not required

Doxorubicin- pegylated liposomal (CAELYX®)

Janssen Class II Richard K. Plante, Director of Oncology, Janssen Tel: 416-382-5078

Mobile: 416-805-4648 e-mail: rplante@its.jnj.com

or Myrna O’ Brodovich, Medical Information, Janssen Tel: 1-800-567-3331

e-mail: medinfocanada@joica.jnj.com

Not required

Enzalutamide (XTANDI®)

Astellas Restricted Funding

XTANDI® Patient Assistance Program Tel: 1-855-982-6348

 Financial assistance is available to all patients with or without third party insurance

 Home delivery available through McKesson Pharmacy

Not required

Eribulin (HALAVEN®)

Eisai Restricted Funding

Eisai Assistance Program Tel: 1-866-601-7340 Fax: 1-866-246-7195 Assistance offered:

 No compassionate supply available

Not required

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DRUG SUPPLIER BCCA CLASS PROGRAM INFORMATION PHARMACARE SPECIAL AUTHORITY Erlotinib

(TARCEVA®)

 Financial assistance and RPAP services end March 31, 2015

InnoviCares - Tarceva® benefit card:

 Program covers up to the difference in the drug ingredient cost between Tarceva® and the respective generic alternatives

 Benefit card can be downloaded from www.innovicares.ca

Not required

Everolimus (AFINITOR®)

Novartis Class II or Restricted Funding based on indication

AfiniTRAC® Reimbursement Support Program Tel : 1-888-623-4648

Fax : 1-866-359-0175 Assistance offered:

Not required

(12)

DRUG SUPPLIER BCCA CLASS PROGRAM INFORMATION PHARMACARE SPECIAL AUTHORITY Fulvestrant

(FASLODEX®)

AstraZeneca Not funded by BCCA

FasloCARE Program Tel: 1-877-327-5644 Fax: 1-877-327-5655 Assistance offered:

 Financial assistance is available to patients with or without third party insurance

 Compassionate supply may be available InnoviCares - Faslodex® benefit card:

 Program covers up to 20% of Faslodex® prescription

 Benefit card can be downloaded from www.innovicares.ca

Faslodex® Injection Support Program (FISP) Tel: 1-855-420-1515

Fax: 1-844-229-1417

Email: Faslodex@innomar-strategies.com Assistance offered:

 Offering injection services for patients with drug supply

Not required

Ibrutinib

(IMBRUVICA®)

Janssen Not funded by BCCA

Imbruvica® YOU&i^TM Patient Support program Tel: 1-844-888-0080

 Financial assistance is available to all patients who have third party insurance coverage but may need help with the co-pay

 Compassionate drug access will end on 30 June 2015

 Home delivery available through McKesson Pharmacy

Not required

Idelalisib (ZYDELIG®)

Gilead Not funded by BCCA

Gilead Oncology Patient Support Program Tel: 1-844-453-6777

 Financial assistance is available to patients with or without

Not required

(13)

DRUG SUPPLIER BCCA CLASS PROGRAM INFORMATION PHARMACARE SPECIAL AUTHORITY Imatinib

(GLEEVEC®)

Novartis Class II GIST Alliance Tel: 1-855-489-4362 Fax: 1-855-788-3159 Assistance offered:

 Program covers up to 20% of drug cost

Not required

Interferon alpha (INTRON A®)

Merck Class I Merck Care^TM Oncology

Not required

Ipilimumab (YERVOY®)

Bristol-Myers Squibb

Restricted Funding

YERVOY® Access to Hope Program Tel: 1-877-967-6626

 Enrolment criteria: not for off-label indications

 Financial assistance and compassionate supply available to all patients with or without third party insurance

coverage on a case-by-case evaluation

 Prescribers must complete a certification program prior to prescribing the drug via

https://www.bmscanada.ca/en/health-care- professionals/yervoy-tools-for-healthcare- professionals-and-patients

Not required

Lapatinib (TYKERB®)

GlaxoSmithKline Restricted Funding

inReach® Patient Support Program Tel: 1-888-475-4255

 Financial assistance is available to patients with or without third party insurance. Patients may be asked to co-pay based on household income

Not required

(14)

DRUG SUPPLIER BCCA CLASS PROGRAM INFORMATION PHARMACARE SPECIAL AUTHORITY Lenalidomide

(REVLIMID®)

Celgene Restricted Funding

RevAid® program Tel: 1-888-738-2431 Fax: 1-877-585-2382 Website: www.revaid.ca Assistance offered:

 Compassionate supply may be available for non-BCCA funded indications

Not required

Letrozole (FEMARA®)

Novartis

Pharmaceuticals

Class I Access FEMARA®

 Compassionate supply of FEMARA® available based on financial need

Not required

Nilotinib (TASIGNA®)

Novartis Restricted Funding

GIST Alliance Tel: 1-855-489-4362 Fax: 1-855-788-3159 Assistance offered:

 Program covers up to 20% of drug cost

Not required

Pazopanib (VOTRIENT®)

GlaxoSmithKline Restricted Funding

inReach® Patient Support Program Tel: 1-888-475-4255

 Financial assistance is available to patients with or without third party insurance. Patients may be asked to co-pay based on household income

Not required

(15)

DRUG SUPPLIER BCCA CLASS PROGRAM INFORMATION PHARMACARE SPECIAL AUTHORITY Pembrolizumab

(KEYTRUDA®)

Merck Canada Not funded by BCCA

MERCK CARE® Oncology Patient Assistance Program Tel: 1-855-549-9416

 Enrolment criteria: Patients with unresectable or

metastatic melanoma and disease progression following ipilimumab therapy and, if BRAF V600 mutation positive, following a BRAF or MEK inhibitor as per proposed indication.

 Financial assistance available to patients with or without third party insurance coverage. Patients may be asked to co-pay based on household income

 Compassionate supply is available based on financial needs

 Patients previously enrolled in the compassionate use program will continue to receive supply for the duration of therapy



Infusion coordination for new patients provided at private infusion clinics – Bayshore HealthCare. For locations in BC, see: www.bayshore.caor email:

keytruda@bayshore.ca

Not required

Pemetrexed (ALIMTA®)

Lilly Class II or Restricted Funding based on indication

ALIMTA® Assistance with Reimbursement of Cost (ARC) Program

 Coordination of third party insurance coverage, including WorkSafeBC

 Based on financial need:

o Financial assistance may be available to patients who have third party insurance coverage but may need help with the co-pay

o Compassionate supply may be available

Not required

(16)

DRUG SUPPLIER BCCA CLASS PROGRAM INFORMATION PHARMACARE SPECIAL AUTHORITY Pertuzumab

(PERJETA®)

Roche Restricted Funding

Roche Patient Assistance Program (RPAP)- Perjeta®

Not required

Pomalidomide (POMALYST®)

Celgene Not funded by BCCA

Pomalyst Access Program Tel: 1-888-738-2431

 Program opens for enrolment until March 31, 2015 Enrolment criteria: failed Bortezomib and Lenalidomide

 Financial assistance is available to all patients with or without third party insurance coverage

 Compassionate drug supply may be available

Not required

Regorafenib (STIVARGA®)

Bayer Not funded by BCCA

ABC STIVARGA program Tel: 1-855-327-4511 Fax: 1-855-206-9788 Assistance offered:

 Financial assistance available to all patients with or without third party insurance coverage

 Program covers up to 20% of drug cost

Not required

(17)

DRUG SUPPLIER BCCA CLASS PROGRAM INFORMATION PHARMACARE SPECIAL AUTHORITY Romidepsin

(ISTODAX®)

Celgene Not funded by BCCA

ISTODAX Access Program Tel: 1-289-291-4841

 Program opens for enrolment until March 31, 2015

 Compassionate supply available to patients enrolled prior to March 31, 2014

 Enrolment criteria: relapsed/refractory Peripheral T-Cell Lymphoma (PTCL) not eligible for stem cell transplant;

failed at least one prior systemic therapy

 Financial assistance available to all patients with or without third party insurance coverage

 No infusion cost assistance

Not required

Rituximab (RITUXAN®)

Not required

Romiplostim (NPLATE®)

eNable Support Program Tel: 1-888-675-2832 Fax: 1-888-675-2835 Assistance offered:

 No compassionate assistance available

Not required

(18)

DRUG SUPPLIER BCCA CLASS PROGRAM INFORMATION PHARMACARE SPECIAL AUTHORITY Ruxolitinib

(JAKAVI®)

Novartis Restricted Funding

Novartis Alliance Program- MPN Alliance Tel : 1-855-489-4362

Fax : 1-855-788-3159 Assistance offered:

Not required

Sorafenib (NEXAVAR®)

Bayer Restricted Funding

Assistance Bayer Canada (ABC) NEXAVAR® Program Tel: 1-800-639-2827

Not required

Temozolomide (TEMODAL®)

Merck Class II Merck Care^TM Oncology Tel: 1-877-494-0454 Fax: 1-877-656-0686 Assistance offered:

Not required

Thalidomide (THALOMID®)

Celgene Restricted Funding

RevAid® program Tel: 1-888-738-2431 Fax: 1-877-585-2382 Website: www.revaid.ca Assistance offered:

 Compassionate supply may be available for non-BCCA funded indications

Not required

Tocilizumab (ACTEMRA®)

Roche Not funded by BCCA

JointEffort® program Tel: 1-888-748-8926 Fax: 1-888-532-1198 Assistance offered:

 Financial assistance is available to all patients who have

Not required

(19)

DRUG SUPPLIER BCCA CLASS PROGRAM INFORMATION PHARMACARE SPECIAL AUTHORITY Trametinib

(Mekinist®)

 Financial assistance is available to patients with or without third party insurance. Patients may be asked to co-pay based on household income

 Patient must be BRAF-positive

 Program does not coordinate or cover cost of BRAF testing

 Home delivery available through BioScript Pharmacy

Not required

Trastuzumab (HERCEPTIN®)

 Infusion coordination provided, if required

Not required

Trastuzumab Emtansine (KADCYLA®)

Roche Patient Assistance Program (RPAP)- Kadcyla®

 Infusion coordination provided, if required

Not required

(20)

DRUG SUPPLIER BCCA CLASS PROGRAM INFORMATION PHARMACARE SPECIAL AUTHORITY Vandetanib

(CAPRELSA®)

AstraZeneca Not funded by BCCA

CAPRELSA® Restricted Distribution Program Tel: 1-800-668-6000

Website: www.caprelsa.ca/rdp.

Assistance offered:

 Prescribing physicians and pharmacists need to complete a certification process and register with the program in order to enrol patients, prescribe and dispense vandetanib (CAPRELSA®).

 No compassionate supply of vandetanib offered by program

 Reimbursement guidance for patients with third party insurance coverage offered by Shoppers Drug Mart Specialty Health Network. Tel: 1-855-212-3922 See:

Drugs with Special Ordering Procedures (SAP chart)

Not required

Vemurafenib (ZELBORAF®)

Roche Patient Assistance Program (RPAP) Tel: 1-888-748-8926

 Financial assistance is available to all patients with or without third party insurance

Not required

Vismodegib (ERIVEDGE®)

Roche Patient Assistance Program/ERIVEDGE®

Pregnancy Prevention Program (RPAP/EPPP) Tel: 1-888-748-8926

 Drug can only be dispensed to patients who are registered and meet all conditions of the EPPP. For more information contact EPPP at 1-888-748-8926

Not required