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IPSEN CARES Enrollment Form
A resource to support your patients prescribed Somatuline Depot.
Your patients prescribed Somatuline Depot who are enrolled in IPSEN CARES can receive individualized support services provided by an IPSEN CARES Nurse to help them through their treatment journey.
Nurse Program Flashcard
*For additional information, download the program brochure on the right
Nurse Home Health Administration (NHHA) is available for patients who have difficulty receiving their Somatuline Depot injections at their doctor’s office. Eligible* patients can have an IPSEN CARES nurse visit their home or work to administer their injections. There is no cost to the patient for this option. NHHA must be requested by the doctor and the patient must be enrolled in IPSEN CARES.
*Patient Eligibility for Nurse Home Healthcare Administration: A physician must prescribe Somatuline Depot to be administered by Home Health Administration for the patient. The program is available to most patients covered by commercial insurance plans. Patients are not eligible if prescriptions are paid in part or fully by any state or federally funded programs, including, but not limited to, Medicare or Medicaid, VA, DoD or TRICARE. Residents of Massachusetts, Michigan, Minnesota, and Rhode Island are not eligible.
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 Somatuline Depot, as supported by information provided in the program application. Patients may enroll through IPSEN CARES. If eligible, they may receive free medication from Ipsen.
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This form is to be used to determine eligibility and to enroll into the Somatuline Depot Copay Assistance Program. This form is intended for patient use only.
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Patients/caregivers are required to sign the Somatuline Depot 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.
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 Somatuline Depot 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 for their Somatuline Depot injection
- 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
IPSEN CARES
Copay Assistance 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.
For patients with commercial insurance, the maximum copay benefit amount per prescription is an amount equal to the difference between the annual maximum copay benefit of $20,000 and the total amount of copay benefit provided to the patient in the Somatuline® Depot Copay Program.
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/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.
A resource to support patients prescribed Somatuline Depot.
Patients prescribed Somatuline Depot who are enrolled in IPSEN CARES can receive individualized support services provided by an IPSEN CARES Nurse to help them through their treatment journey.
Nurse Program Flashcard
*For additional information, download the program brochure on the right
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.
Nurse Home Health Administration (NHHA) is available for patients who have difficulty receiving their Somatuline Depot injections at their doctor’s office. Eligible* patients can have an IPSEN CARES nurse visit their site of choice to administer their injections. There is no cost to the patient for this option. NHHA must be requested by the doctor and the patient must be enrolled in IPSEN CARES.
*Patient Eligibility for Nurse Home Healthcare Administration: A physician must prescribe Somatuline Depot to be administered by Home Health Administration for the patient. The program is available to most patients covered by commercial insurance plans. Patients are not eligible if prescriptions are paid in part or fully by any state or federally funded programs, including, but not limited to, Medicare or Medicaid, VA, DoD or TRICARE. Residents of Massachusetts, Michigan, Minnesota, and Rhode Island are not eligible.
Patients may be eligible for free medication through our PAP. Patients may be eligible to receive free drug if they 1) are experiencing financial hardship, 2) are uninsured or functionally uninsured, 3) are US residents, 4) received a prescription for an on-label use of an Ipsen medication as supported by information provided in the program application, and 5) meet income criteria based on Experian soft credit check. Eligibility does not guarantee approval for participation in the program.
The PAP provides Somatuline Depot product only, and does not cover the cost of previously purchased product or medical services.