PROGRAM APPLICATION | Radius Health

PATIENT ELIGIBILITY CRITERIA:

Medicare Beneﬁciary Commercially-Insured but Not Covered Uninsured

• Patient must have an FDA-approved, on-label

diagnosis for TYMLOS

(abaloparatide) injection

• Patient must have an Annual Household Income

<300% Federal Poverty Level (FPL)*

• Patient must be a legal resident of the contiguous

United States, Alaska, or Hawaii

• Patient must not be enrolled in Medicaid, Tricare,

Veterans Health Administration, or Indian Health

Service beneﬁt programs

• Patient must not be enrolled in full Low-

Income Subsidy (LIS)

†

from the Social Security

Administration

• Patient must not be eligible for State Pharmacy

Assistance Programs in which TYMLOS

participates

• Patient must have an FDA-approved, on-label

diagnosis for TYMLOS

(abaloparatide) injection

• Patient must have an Annual Household Income

<300% Federal Poverty Level (FPL)*

• Patient must be a legal resident of the contiguous

United States, Alaska, or Hawaii

• Patient must not be enrolled in Medicaid, Tricare,

Veterans Health Administration, or Indian Health

Service beneﬁt programs

• Patient must have neither insurance coverage

for nor access to other coverage for TYMLOS

• Patient must have an FDA-approved, on-

label diagnosis for TYMLOS

(abaloparatide)

injection

• Patient must have an Annual Household

Income <300% Federal Poverty Level (FPL)*

• Patient must be a legal resident of the

contiguous United States, Alaska, or Hawaii

• Patient must not be enrolled in a Medicare

or commercial prescription drug plan

or Medicaid, Tricare, Veterans Health

Administration, or Indian Health Service

beneﬁt programs

Patients Prescribers

• Sections 1 through 5 completed in their entirety (page 2)

• Section 4 signed and dated (hard copy/wet signature required)

• Copy of insurance card(s) and pharmacy beneﬁts card(s) (front and back)

• Copy of most recent proof of income (e.g., Form 1040, Form 1099, Form SSA 1099, etc.)

• A signed and notarized Power of Attorney (POA) for signatures other than the patient’s

original signature

• Sections 6 and 7 completed in their entirety (page 3)

• Section 7 signed and dated (hard copy/wet signature required)

• For commercially-insured patients, a copy of prior authorization

and appeal denial(s) must be submitted

DO NOT INCLUDE PATIENT MEDICAL RECORDS

*Find current U.S. Federal Poverty Guidelines online at www.aspe.hhs.gov/poverty-guidelines

†

To apply for LIS, please contact the Social Security Administration at (800) 772-1213 (T TY 800-325-0778) or go to https://secure.ssa.gov/i1020/start

INSTRUCTIONS:

1. Complete all fields to ensure application can be processed

2. Make sure the application is signed and dated by the prescriber

3. Make sure the application is signed and dated by the patient

4. Include all Required Documentation (see below)

5. Send completed application and required documents:

Fax to 1-800-910-4610 or Mail to

Radius Assist Patient Assistance Program (PAP)

2503 E 54

Street N

Sioux Falls, SD 57104

REQUIRED DOCUMENTATION:

ADDITIONAL INFORMATION:

• Patients and prescribers will be notiﬁed by phone or mail

of the approval or denial of the application

• Please allow up to 4 weeks for application processing

• Approved patients may receive up to a 3-month supply

of medication at a time, for up to 12 months, subject to

continued eligibility and pursuant to a valid prescription

• Questions? Patients and prescribers may call

Radius Assist at

1-866-896-5674

PROGRAM APPLICATION

(Last):

(front and back)

(First):

(For income veriﬁcation)

Do you have insurance? (Check all that apply.)

Medicaid Veterans Health Administration Tricare

Medicare Part D Plan Full low income subsidy (LIS/”Extra Help”) Indian Health Service

None State Pharmacy Assistance Program Other:

Have you included proof of income documentation?

Send at least 1 document that shows your income, such as last year’s Federal Income Tax return or Social Security state-

ment.Patients who only receive Social Security may submit a Social Security statement provided there were no other sources

of income during the calendar year (subject to program veriﬁcation).

5. PATIENT AUTHORIZATION

4. PATIENT CERTIFICATION

3. PATIENT HOUSEHOLD INCOME INFORMATION

2. PATIENT INSURANCE INFORMATION

1. PATIENT INFORMATION

PATIENT AUTHORIZATION TO SHARE HEALTH INFORMATION: I authorize my healthcare providers, my health plan, and insurers to give health and other information about my use or need

for medications provided under Radius Assist to third-party Radius vendors in charge of administering the PAP. My health and other information are referred to below as “Information.”

I authorize Radius Assist, Radius, their agents, and thirdparty contractors or their service providers to further use and disclose my Information in connection with the PAP. I

understand: (1) That my Information will include my name, address, Social Security number, income, prescription coverage, prescription for medication(s), ﬁnancial documents,

insurance records, and any other information provided on this form. (2) That people with the PAP, Radius, or others working on behalf of the PAP may see and use my Information for

administering the PAP. (3) That my Information may be used to see if I meet the eligibility requirements to participate in the PAP, to obtain a credit report to help estimate my income as

part of the eligibility determination process, to help me enroll in the PAP (if I am eligible), to ﬁnd out whether I may be eligible for, or am already enrolled in, another program (including

an insurance plan or other charitable program), to ship appropriate medication(s), and to contact me to seek feedback on Radius Assist services. (4) That I will be notiﬁed by the PAP

if I do not meet the requirements to participate in the PAP.

WITHOUT LIMITING THE PURPOSES FOR THE DISCLOSURE OF INFORMATION SET FORTH ABOVE, I UNDERSTAND: (1) That the PAP, Radius, their agents, and third party contractors or service

providers will keep my Information private, but that federal privacy laws may no longer protect my Information once it is disclosed, and that my information may be legally

re-disclosed by recipients if not prohibited by state law. (2) That this authorization will expire 1 year from the date this form is signed unless I cancel it in writing. (3) That I may cancel

this authorization at any time by giving written notice to Radius at the address on this form, but my cancellation will not change any actions taken with my Information prior to

cancelling, and my enrollment in the PAP will end. (4) That I have the right to receive a copy of this authorization from my healthcare provider and/or Radius, and that I may

inspect/obtain a copy of the information disclosed pursuant to this authorization. (5) That I can refuse to sign this form, and that if I refuse to sign, it will not change the way that my

healthcare providers, health plans, and insurers treat me. (6) That if I do not sign this form, I will not be able to participate in the PAP.

PATIENT DECLARATION:

I CERTIFY: (1) I do not have the ability to pay for the medication(s) requested by my healthcare provider on the attached prescription(s). (2) I will notify Radius Assist within thirty (30)

days if my ﬁnancial status or health insurance coverage changes. (3) I will not sell, trade, or distribute any products given to me via Radius Assist. (4) I will verify my PAP application

status and receipt of the indicated medication(s) upon request by Radius Assist. (5) If I receive free product through Radius Assist, I certify that I will not seek reimbursement or credit

for this prescription from any insurer, health plan, or government program, including Medicare and Medicaid. (6) If I am a member of a Medicare Part D plan, I will not seek to have this

prescription or any cost associated with it counted as part of my True Out-of-Pocket (TrOOP) cost for prescription drugs. (7) All of the information provided in this application, including

household income and insurance, is complete and accurate.

I UNDERSTAND AND AGREE: (1) That program assistance will terminate if the PAP becomes aware of any fraud or if this medication is no longer prescribed for me. (2) That completing

this application does not ensure that I will qualify for patient assistance, and that my eligibility to participate in Radius Assist is subject to the decision of Radius. (3) That I may be

required to provide proof of ineligibility for certain other prescription coverage programs in order to meet the eligibility requirements for the PAP. (4) That Radius Assist reserves the

right to modify the application form, modify or discontinue this program, or terminate assistance at any time and without notice.

(5) That I may choose to opt out of Radius Assist at any time by notifying a representative at 1-866-896-5674 or by notifying the program in writing at the address listed above.

(6) I authorize Radius Assist and it

s administrator to forward this prescription to a dispensing pharmacy on my behalf.

6. PRESCRIBER INFORMATION

7. PRESCRIPTION AND PRESCRIBER CERTIFICATION

-866-896-5674

1-800-910-4610

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Street Address:

Practice Street Address:

Practice Name:

Concurrent Medications:

Pertinent Medical History:

Allergies:

Date of Birth:

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