Treatment & Service Request Form

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PATIENT/RESIDENT INFORMATION & INSURANCE

DIAGNOSIS/PRESCRIBER INFORMATION

PRESCRIPTION INFORMATION

NUPLAZID

(pimavanserin) ONGOING PRESCRIPTION

FREE 14-DAY SUPPLY OF NUPLAZID

(pimavanserin)

Please complete and fax to 1-844-737-2224, email to [email protected], or complete the online form at acadiaconnect.com.

Please note that email communications sent to Acadia or its third-party service providers may not be encrypted or secured, and safeguards

established under the HIPAA Security Rule would not apply to these communications. See Indication and Important Safety Information, including

Boxed WARNING, on page 2. Please read accompanying full Prescribing Information, also available at NUPLAZIDhcp.com.

Prescriber Authorization: I attest that I have obtained written permission, in the event it is required under applicable federal and/or state law, of my patient (or the patient’s legal representative) for the release of

my patient’s Protected Health Information (“PHI”) to Acadia Pharmaceuticals Inc. or its representatives or agents (collectively “Acadia”) as may be necessary for the patient’s participation in a program designed to

assist patients in determining their insurance coverage for NUPLAZID that I have elected to prescribe. I direct Acadia to convey, on my behalf, any prescription information delivered to Acadia for NUPLAZID by any

means under applicable law to the dispensing pharmacy chosen by or for the patient, to the patient’s health insurance company, or to other third parties as may be necessary to assist this patient with lling his/her

prescription for NUPLAZID, with securing any insurance coverage for NUPLAZID to which the patient is entitled, or other third parties to assist with patient assistance or reduced-cost medication. I understand I am

to comply with the state-specic prescription requirements such as e-prescribing, state-specic prescription form, fax language, etc. I agree that Acadia may contact me for additional information relating to

NUPLAZID, including but not limited to via email, fax, and telephone. I authorize Acadia to transmit the above prescription to the pharmacy.

Phone: 1-844-737-2223

Fax: 1-844-737-2224

Long-term care: 1-877-889-0739

*Indicates required eld.

Please fax copies of the front and back of prescription insurance cards.

*Patient rst name

*Prescriber or authorized agent signature

(No stamp allowed) *Date

*Prescriber rst and last name *Prescriber NPI number State license number

(If available)

Practice/Facility name *Address

Primary contact name *City *State *ZIP

Prescriber email *Phone number

*Prescriber signature

*Prescriber signature Date

Prescriber signatureDate Date

*Fax

*Facility name *Facility phone number

Address City State ZIP

Facility contact name Job title

Pharmacy name Pharmacy phone number NUPLAZID

(pimavanserin) Order on File:

Check this box if your resident is currently covered under Medicare Part A; expected discharge date:

LONG TERM CARE FACILITIES If “Assisted living” or “Skilled nursing facility/nursing home” is selected, please complete the information below. Skip Section 3 if not needed for resident.

Section required if patient has insurance

*Patient last name *Prescription drug plan

*Address *ID number Phone number*City

*State Plan number Group number*ZIP *DOB

(MM/DD/YYYY) Gender

*Patient phone number PCN BIN number*Preferred contact:

*Caregiver name Medicare Beneciary ID

*Caregiver phone number Preferred language, if not English

Patient email/Caregiver email

Preferred pharmacy name

*Patient resides:

Hallucinations and delusions associated with Parkinson’s disease psychosis (PDP).

None None

Already provided prescription to

E-prescription already sent to RareMed Pharmacy Other

†

Rells (# of rells):

sig. Take 34 mg capsule orally, once daily

sig. Take 34 mg capsule orally, once daily Dispense: 30-day supply Other

†

# of days to be dispensed:

(pharmacy name)

Will e-prescribe once Acadia Connect conrms appropriate pharmacy

Known drug allergies:

Dispense as

written

Acadia Connect

may send

a second Free 14-Day Supply

if extra time is needed.

Substitution

permitted

Concurrent medications (attach list, if more space is needed):

Skip this section if NUPLAZID

(pimavanserin) order is on le for long term care resident.

If marking checkbox for ongoing prescription already sent to pharmacy or prefer to e-prescribe, skip prescription elds.

Note: Limited to a 14-day supply per ll

(only for patients diagnosed with hallucinations and delusions associated with PDP)

Note: Free 14-day Supply of NUPLAZID to be dispensed by RareMed Pharmacy.

NUPLAZID will only be dispensed and delivered to facilities that accept free product.

†

See Important Safety Information for dosing recommendations (including drug/drug interactions).

ACAC-0151-v2-WEB 09/23

14-day supply with 1 rell

34 mg capsule

Other diagnosis: Other:

*Conrmation of diagnosis required *Please conrm dose:

Patient

At home Assisted living Skilled nursing facility/nursing home

Caregiver

Yes No

Patient does not have insurance

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I hereby authorize and direct my health care providers (including

physicians providers of long-term care, and pharmacies) and health

insurance companies and each of their respective representatives,

employees, staff, and agents (collectively “Providers”) to disclose

my Protected Health Information (“PHI”) to Acadia Pharmaceuticals

Inc. and its representatives and agents (collectively “Acadia”) for

obtaining Acadia Connect support services. I understand that

this PHI may include, but is not limited to, my name, address,

phone number, and other contact information; information relating

to my medical condition, treatment, care management, and

health insurance; as well as information provided on this form

and any prescription. I understand that pharmacies may receive

remuneration (payment) from Acadia for providing patient support

services and disclosing associated PHI to Acadia pursuant to

this Form.

I authorize Acadia to use and further disclose the PHI it receives

as a result of this Form for:

• Providingreimbursementsupportassociatedwiththellingofmy

prescription,includingvericationofmyinsurancebenetsand

assistance in securing coverage to which I am entitled.

• Facilitating the provision of patient assistance, reduced-cost

medication, co-pay assistance, and/or other product-related

services offered by Acadia, patient advocacy organizations, or

other third parties.

• Sending me communications related to the Acadia Connect

support services.

• Administrative purposes related to the above services.

• Followingde-identication,useforresearchpurposes.

I authorize Acadia to contact me using the contact information I

have provided this Form for the above purposes. I also authorize

Acadia to report back to my Providers any PHI about me that

Acadia may create or receive.

I understand that once my PHI is disclosed to Acadia pursuant to

this Form, it may be no longer be protected by the Health Insurance

Portability and Accountability Act (HIPAA) and may be subject to

re-disclosure.

I understand that I may refuse to sign this Form and my refusal will

not affect the treatment I receive from my Providers, nor will it affect

myenrollmentoreligibilityforhealthinsurancebenetstowhichI

am otherwise entitled. I also understand that I may cancel (revoke)

this authorization at any time by mailing a letter requesting such

cancellation to the address below; however, this cancellation will

not apply to any PHI already used or disclosed in reliance on this

Form before notice of the cancellation is received by my Providers.

I understand that this authorization is valid for a period of 10 years

or for a shorter period dictated by applicable state law. I understand

that I will be provided with a signed copy of this authorization by the

Provider who collects it from me.

Further information concerning Acadia’s privacy practices can

be found at https://www.acadia-pharm.com/privacy. If you are a

resident of California, a description of the personal information

collected by Acadia and your rights under the California Consumer

Privacy Act can be found at this address.

Address to Opt Out of Communications or to Cancel This Form:

Acadia Connect, PO Box 15713, Pittsburgh, PA 15244

AUTHORIZATION TO DISCLOSE INFORMATION TO INDIVIDUALS INVOLVED IN MY CARE (optional)

Patient signature Date

I further authorize Acadia Pharmaceuticals Inc. to discuss the coordination of my care with the following family member(s) and/or caregiver(s):

Authorized representative Name (please print)

Patient signature/legal guardian signature

Indication

NUPLAZID is indicated for the treatment of hallucinations and delusions associated

with Parkinson’s disease psychosis.

Important Safety Information

WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-

RELATED PSYCHOSIS

•

Elderly patients with dementia-related psychosis treated with antipsychotic

drugs are at an increased risk of death.

•

NUPLAZID is not approved for the treatment of patients with dementia who

experience psychosis unless their hallucinations and delusions are related

to Parkinson’s disease.

•

Contraindication: NUPLAZID is contraindicated in patients with a history of a

hypersensitivity reaction to pimavanserin or any of its components. Rash, urticaria,

and reactions consistent with angioedema (e.g., tongue swelling, circumoral edema,

throat tightness, and dyspnea) have been reported.

•

Warnings and Precautions: QT Interval Prolongation

NUPLAZID prolongs the QT interval. The use of NUPLAZID should be avoided

in patients with known QT prolongation or in combination with other drugs known

to prolong QT interval (e.g., Class 1A antiarrhythmics, Class 3 antiarrhythmics,

certain antipsychotics or antibiotics).

NUPLAZID should also be avoided in patients with a history of cardiac arrhythmias,

as well as other circumstances that may increase the risk of the occurrence of

torsade de pointes and/or sudden death, including symptomatic bradycardia,

hypokalemia or hypomagnesemia, and presence of congenital prolongation of the

QT interval.

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Adverse Reactions: The adverse reactions (≥2% for NUPLAZID and greater than

placebo) were peripheral edema (7% vs 2%), nausea (7% vs 4%), confusional

state (6% vs 3%), hallucination (5% vs 3%), constipation (4% vs 3%), and gait

disturbance (2% vs <1%).

•

Drug Interactions:

Coadministration with strong CYP3A4 inhibitors increases NUPLAZID exposure.

Reduce NUPLAZID dose to 10 mg taken orally as one tablet once daily.

Coadministration with strong or moderate CYP3A4 inducers reduces

NUPLAZID exposure. Avoid concomitant use of strong or moderate

CYP3A4 inducers with NUPLAZID.

Dosage and

Administration

Recommended dose: 34 mg capsule taken orally once daily, without titration, with or

without food.

NUPLAZID is available as 34 mg capsules and 10 mg tablets.

Please read the accompanying full Prescribing Information, including Boxed

WARNING, also available at NUPLAZIDhcp.com.

Date

Relationship to patient

Personal representative (if applicable) signature Date

HIPAA AUTHORIZATION

Please read and sign below if you agree.