Patient support for eligible and enrolled patients prescribed Dysport

Once the provider has prescribed Dysport® (abobotulinumtoxinA) for injection, the IPSEN CARES® Patient Access Specialists are fully dedicated to:

Facilitating eligible patients’ access to their prescribed medications
Providing information and support for the interactions among offices, patients, and insurance companies for Ipsen medications

Actual patient who has been compensated for her time.
We are collecting personal information in order to fulfill your request. Please see Ipsen’s privacy policy at https://www.ipsen.com/us/privacy-policy/

Home > Dysport > HCP Program Enrollment

For HCPs

Program Enrollment | Additional Resources

For Patients/Caregivers

Program Enrollment | Additional Resources

IPSEN CARES Program Enrollment Is Quick and Easy

Eligible Patients must be enrolled to access all IPSEN CARES support offerings.

STEP
1

Patient and HCPs can fill out the IPSEN CARES Enrollment Form at the office. The form can either be filled out online and then submitted electronically, or it can be printed and then faxed to IPSEN CARES. The patient can also self-enroll.

STEP
2

Once a completed Enrollment Form is received, an IPSEN CARES Patient Access Specialist will conduct a benefits verification to review the patient’s out-of-pocket costs associated with the Ipsen medication. Additional support offerings for which the patient may be eligible will be discussed at that time.

Complete and Submit
IPSEN CARES Enrollment Form

OR

Watch Mike Enroll in the IPSEN CARES Dysport Copay Program in 3 Easy Steps

Learn more about the IPSEN CARES Copay Program by visiting the Patient Enrollment section.

C.L.I.M.B.® Injection Training

(Continuum of Learning to Improve Management with Botulinum Toxin)

C.L.I.M.B.® is a multitiered learning continuum designed to accommodate physicians with every level of experience with botulinum toxin therapy. C.L.I.M.B.® will help physicians across all levels improve their clinical skills relating to the appropriate use of Dysport through hands-on injection training, online activities, and educational materials.

Free Medication

Uninsured patients may be eligible for free medication through our Patient Assistance Program. Patients may be eligible to receive free drug if they are experiencing financial hardship, have no insurance coverage, and received a prescription for an on-label use of Dysport, as supported by information provided in the program application. Patients may enroll through IPSEN CARES. If eligible, they may receive free medication from Ipsen.

Patient Assistance Program Application

OR

Letter Templates to Download/Print

Letter of Medical Benefit Coverage

Letter of Appeal

Letter of Medical Necessity

Med D Tier Exception

Patient and Prescribing Information

Medication Guide for Dysport® (abobotulinumtoxinA)

Full Prescribing Information for Dysport® (abobotulinumtoxinA), including Boxed Warning

Helpful Guides to Download/Print

Dysport® (abobotulinumtoxinA) Resource Guide

IPSEN CARES Self-Enrollment Is Quick and Easy

Patients must be enrolled to access all IPSEN CARES support offerings.

STEP
1

Patients can fill out the IPSEN CARES Self-Enrollment Form. The can either be filled out online or printed and faxed to IPSEN CARES.

This form is to be used to determine eligibility and to enroll into the Dysport Copay Assistance Program. This form is intended for patient use only.

STEP
2

Once a completed Self-Enrollment Form is received, an IPSEN CARES Patient Access Specialist will conduct a benefits verification to review the patient’s out-of-pocket costs associated with the Ipsen medication. Additional support offerings for which the patient may be eligible will be discussed at that time.

IPSEN CARES Self-Enrollment Form

OR

Patient Authorization

Patients/caregivers are required to sign the Dysport Patient Authorization Form every 3 years or sooner if required by state law to give the Patient Access Specialists at IPSEN CARES permission to access the patient’s personal health information in order to help with treatment. The form can be signed and submitted online, or by downloadable PDF, which must be printed, filled out, signed, and faxed.

IPSEN CARES Patient Authorization Form

OR

Help With Copays?

Check for copay coverage. Considering that some patients need financial assistance, our copay assistance programs may help eligible* patients with the cost of their treatment.

The Dysport Copay Program for eligible, commercially insured patients is available by enrolling in IPSEN CARES. Here is the key information:

Patients may pay as little as $0 per prescription
For patients utilizing the Pharmacy Benefit, we will provide the virtual pharmacy copay card information on behalf of the patient directly to the specialty pharmacy being utilized
For patients utilizing the Medical Benefit, we will send details for claims processing on behalf of the patient directly to the doctor’s office
For Self-Enroll patients, they must complete/submit the Member Reimbursement Form for Medical Reimbursement Requests
For patients who are eligible for government health benefits (eg, Medicare, Medicaid, TRICARE), IPSEN CARES may be able to offer the contact information for independent nonprofit foundations that may be able to offer financial assistance

Dysport Copay Assistance Flashcard

Copay Reimbursement Process Flashcard

IPSEN CARES Patient Copay Flashcard

Member Reimbursement Form

*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, 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.

In any calendar year commencing January 1, the maximum copay benefit amount paid by Ipsen Biopharmaceuticals, Inc. will be $5,000.

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 CoverMyMeds 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.

Free Medication

Uninsured patients may be eligible for free medication through our Patient Assistance Program. Patients may be eligible to receive free drug if they are experiencing financial hardship, have no insurance coverage, and received a prescription for an on-label use of Dysport, as supported by information provided in the program application. Patients may enroll through IPSEN CARES. If eligible, they may receive free medication from Ipsen.

Patient Assistance Program Application

Medication Reminder Program

The Medication Reminder Program has many different types of messages to encourage patients to stay on their prescribed medication plan, including reminders about refills at Specialty Pharmacies, changes in insurance, IPSEN CARES re-enrollment, and healthcare provider appointments. Patients can opt-in on the IPSEN CARES Enrollment Form.

Medication Reminder Program

Patients and Healthcare Providers can also call IPSEN CARES at (866) 435-5677

California residents, please click here to download the California Consumer Protection Act (CCPA) Privacy Notice to California Consumers for IPSEN CARES

- + Click Here to Watch the IPSEN CARES Online Enrollment Tutorial Video

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