JazzCares | Modeyso Patients

JazzCares is designed to give you the support and assistance you need, right from the start, and throughout your treatment journey.

Sign the Patient Consent form to start the enrollment process and see if you are eligible for the JazzCares services described below

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Personalized Resources, Nursing, and Pharmacy Support

Dedicated Care Coordinator

Once enrolled, your dedicated Care Coordinator is available to work with you or the person you care for to discuss available support services and resources, and help you navigate your treatment journey.

Pharmacy and Nursing Support

The specialty pharmacy will contact you to coordinate medication shipment, provide medication counseling, as appropriate, and schedule refills to help support continuity of therapy. Pharmacists and nurses are also available to answer any questions or concerns about your medication.

Savings and Support Programs

Copay Program

If you have commercial insurance, you may be eligible to pay as little as $0 out of pocket for your prescription.

Terms and Conditions apply.

Quick Start Program

Are you waiting for your insurance to cover MODEYSO? You may be eligible to receive a temporary free supply of medication so you can start treatment.

Terms and Conditions apply.

Bridge Program

Did you experience a change or interruption in your insurance coverage? You may be eligible to receive a temporary free supply of MODEYSO so you can stay on treatment.

Terms and Conditions apply.

Patient Assistance Program

JazzCares may have you covered, even if you do not have coverage.

If you are uninsured or your insurance does not cover MODEYSO, you may be eligible to receive treatment for free.

Terms and Conditions apply.

Terms and Conditions

Copay Program

Eligible patients may pay as low as $0 per MODEYSO prescription. Monthly and/or annual maximum limits may apply. The copay savings program is only available to patients enrolled in the JazzCares for MODEYSO Patient Support Program who have commercial insurance coverage with out-of-pocket expenses, including copayments, co-insurance, and deductibles. The copay savings program is not valid for beneficiaries of Medicare, Medicaid, VA/DoD (TRICARE) programs, the Indian Health Service or other federal or state healthcare programs, if patient pays for prescription in cash or if patient chooses not to use their insurance coverage. The program is only available for residents of, with a valid current address in the US and Puerto Rico. The copay savings program requires a valid, signed prescription for MODEYSO. The pharmacy will bill patient’s insurance for the portion that patient’s insurance plan has agreed to cover. The copay savings program is not health insurance. The pharmacy, patient, or prescriber cannot submit a claim for reimbursement under any federal, state, or other governmental programs or to any third party for any part of the benefit received by the patient through the copay savings program. By using this offer, patients or their representative certify that they will comply with any terms of their health insurance contract requiring notification to their payer of the existence and/or value of this offer. The copay savings program may not be used with any other coupon, discount, prescription savings card, free trial, or other offer. It is illegal to (or offer to) sell, purchase, or trade this offer. This offer is non-transferable. This offer is void where prohibited by law. No purchase necessary. Copay savings program benefits may not be applied retroactively. If patient’s insurance changes, the pharmacy must be notified immediately. Based on patient’s insurance change, patient may no longer be able to participate in the copay savings program. Jazz Pharmaceuticals reserves the right to terminate or modify this program at any time and without notice and in its sole discretion. In administering the copay savings program, Jazz will process patient’s personal information in accordance with Jazz Pharmaceuticals’ Privacy Policy, https://www.jazzpharma.com/privacy-statement/.

Quick Start Program

The Quick Start program is for new patients who have been prescribed MODEYSO for its FDA-approved indication, are enrolled in the JazzCares for MODEYSO Patient Support Program, and who experience a delay in obtaining coverage for MODEYSO. The program is good for up to four 14-day free supplies for a patient’s first-time prescription. There is a lifetime limit of one Quick Start per patient. The program is for commercially insured patients as well as beneficiaries of Medicare, Medicaid, VA or other federal or state healthcare programs. Patients who pay cash for their prescriptions or who are uninsured are not eligible for the MODEYSO Quick Start Program. The program is only available for residents of, with a valid current address in the US and Puerto Rico. The program requires a valid, signed prescription for MODEYSO. The program may not be submitted by the patient, pharmacy, or prescriber to seek reimbursement for all or any part of the benefit received by the patient through this program. The free supply of MODEYSO cannot be used toward any out-of-pocket costs under any health insurance or prescription drug plan. The program may not be applied retroactively and does not cover refills. The program cannot be combined with any other voucher, certificate, coupon, rebate, or similar offer. Use of the program is not contingent on any purchase requirement. This is not a discount, rebate, or insurance program. The program is not valid where otherwise prohibited by law. It is illegal for any person to sell, purchase, trade, or counterfeit this offer. Jazz Pharmaceuticals reserves the right to terminate or modify this program at any time with or without notice. In order to facilitate the MODEYSO Quick Start Program, you understand and agree that Jazz will process your personal information in accordance with Jazz Pharmaceuticals’ Privacy Policy, which can be found at www.jazzcares.com.

Bridge Program

The Bridge program is for patients who are currently taking MODEYSO, are enrolled in the JazzCares for MODEYSO Patient Support Program, and who experience a coverage interruption for MODEYSO. The program is good for up to two 14-day free supplies. There is no limit to non-consecutive use of the Bridge Program. Patients who pay cash for their prescriptions are not eligible for the MODEYSO Bridge Program. The program is only available for residents of, with a valid current address in the US and Puerto Rico. The program requires a valid, signed prescription for MODEYSO. The program may not be submitted by the patient, pharmacy, or prescriber to seek reimbursement for all or any part of the benefit received by the patient through this program. The free supply of MODEYSO cannot be used toward any out-of-pocket costs under any health insurance or prescription drug plan. The program may not be applied retroactively and does not cover refills. The program cannot be combined with any other voucher, certificate, coupon, rebate, or similar offer. Use of the program is not contingent on any purchase requirement. This is not a discount, rebate, or insurance program. The program is not valid where otherwise prohibited by law. It is illegal for any person to sell, purchase, trade, or counterfeit this offer. Jazz Pharmaceuticals reserves the right to terminate or modify this program at any time with or without notice. In order to facilitate the MODEYSO Bridge Program, you understand and agree that Jazz will process your personal information in accordance with Jazz Pharmaceuticals’ Privacy Policy, which can be found at www.jazzcares.com.

Patient Assistance Program

^*Subject to eligibility criteria. Terms and conditions are available upon request by contacting JazzCares at 1-844-302-2737.

Resources

JazzCares Patient Consent Form:

In order to receive JazzCares services, please complete, sign, date, and send the JazzCares Patient Consent to the JazzCares Program using one of these methods:

Mail to:
13410 Eastpoint Centre Drive
Louisville, KY 40223

Fax to:
1-833-501-2400

Email to:
JazzCares@onco360.com

Download (English) Descargar (Español)

Foundations & Resources Information:

These links will open third-party websites, not sponsored by Jazz, JazzCares, or MODEYSO.

American Brain Tumor Association (ABTA) DIPG OneLink My DIPG Navigator Tough2gether National Brain Tumor Society (NBTS) The Cure Starts Now The DIPG / DMG Resource Network

Insurance coverage and plans may vary. The JazzCares program at Jazz Pharmaceuticals provides general information only and is not a guarantee of any coverage or reimbursement outcome. All treatment decisions rest solely with the treating physician or qualified healthcare professional. Jazz Pharmaceuticals reserves the right to terminate or modify this program at any time with or without notice. Other terms and conditions apply.

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Patient Authorization Disclosure

Uses and Disclosure of Health Information
I hereby authorize and direct my prescriber(s) and their staff, my health insurer(s), and the Specialty Pharmacy that will fill my prescription (the “Pharmacy”) to disclose my name (and the name of my caregiver if applicable), gender, date of birth, contact information, and the following information (together “Health Information”) to Jazz Pharmaceuticals (including its affiliates and services providers acting as data processors) (together “Jazz Pharmaceuticals” or “Jazz”) for any Jazz-sponsored patient support programs and activities, including the JazzCares^® program:

Information concerning my treatment with Jazz Pharmaceuticals’ products, including relevant diagnoses and prescriptions; and
Information about my health insurance benefits, including deductibles and out-of-pocket costs

I understand and authorize Jazz Pharmaceuticals to use and further disclose my Health Information it receives as a result of this Form for the following purposes:

operating, administering, enrolling me in, and/or continuing my participation in the JazzCares^® program or any other Jazz-affiliated patient support services and activities related to my condition or treatment;
verifying, investigating, coordinating, and resolving insurance coverage or reimbursement inquiries and payment for Jazz Pharmaceuticals’ products;
coordinating my receipt of and payment for Jazz Pharmaceuticals’ products;
contacting me about any Jazz-sponsored patient support programs and activities, including the JazzCares^® program (this may include supplemental educational materials, information, offers, and services related to my therapy or my medical condition or opportunities to participate in focus groups, surveys or interviews);
contacting and providing my Health Information to patient advocacy organizations, patient assistance programs, co-pay assistance, or similar programs to determine eligibility for coverage and enrollment;
de-identifying my Health Information by aggregating it for research purposes;
managing Jazz-sponsored patient support programs and activities, including the JazzCares^® program and administrative purposes that support these services and programs

I understand Jazz Pharmaceuticals will not sell my Health Information to third parties, but Jazz Pharmaceuticals may disclose such information to its affiliates and services providers for the purpose described in this Form. I also understand that if I do not consent to the use of my Health Information for the above purposes, I will not be able to participate in Jazz-sponsored patient support programs and activities, including the JazzCares^® program.

I understand and authorize Jazz Pharmaceuticals to contact me using the contact information provided to Jazz to enroll me in, operate, and administer any Jazz-sponsored patient support services, including the JazzCares^® program, through a variety of means including email, postal mail, phone, fax, or SMS/text unless I opt out of these communications by contacting Jazz Pharmaceuticals using the contact information below. I understand that the operation and administration of certain of these services and/or programs may require that Jazz contact me by telephone or SMS/text.

I understand Jazz Pharmaceuticals may report back to my prescriber(s) and their staff, my health insurer(s), or the Pharmacy any Health Information about me that Jazz Pharmaceuticals may create or receive. I understand that my health insurer(s), Pharmacy, and third-party vendor(s) may receive remuneration (payment) in exchange for disclosing my Health Information to Jazz Pharmaceuticals (including JazzCares^®, its affiliates, and services providers acting as data processors) and/or for providing me with support services for the purposes described above.

I understand that after my Health Information is transmitted to Jazz Pharmaceuticals, it may no longer be protected by the Health Insurance Portability and Accountability Act (HIPAA). However, Jazz Pharmaceuticals will not disclose my Health Information to a third party that is not related to the patient support programs (such as a family member or friend) unless I specifically authorize Jazz to do so. If I request that a person or an entity other than Jazz Pharmaceuticals receives my Health Information, I understand the receiver may not be subject to HIPAA or other privacy laws, and the Health Information might be re-disclosed by the recipient.

No Effect on Treatment
I understand that I may refuse to sign this Form and my refusal will not affect the treatment I receive from my prescriber(s) and their staff, my health insurer(s), and the Pharmacy, nor will it affect my enrollment or eligibility for health insurance benefits to which I am otherwise entitled.
Expiration, Right to Obtain a Copy, and Right to Revoke
This Form will remain valid until termination of enrollment in Jazz-sponsored patient support programs and activities, including the JazzCares^® program, unless a shorter time is required by state law.

I understand the program may be changed or ended at any time without prior notification. I understand I may request a copy of this Form that is on file with Jazz. I also understand that I can withdraw my consent to the processing of my Health Information for the above purposes and revoke this Form at any time by calling 1-866-997-3688 or sending my request to: Jazz Pharmaceuticals, PO Box 5490, Louisville, KY 40255. If I do so, I will no longer be eligible to participate in Jazz-sponsored patient support programs and activities, including the JazzCares^® program.

I understand that should I revoke this Form, the revocation will not impact uses and disclosures of my Health Information that have already occurred in reliance on this Form.

More Information on Jazz Pharmaceuticals’ Privacy Practices
Further information concerning Jazz Pharmaceuticals’ privacy practices can be found at https://privacy.jazzpharma.com/united-states/en/jazz-pharmaceuticals-privacy-center. If you are a resident of California, a description of the Health Information collected by Jazz Pharmaceuticals and your rights under the California Consumer Privacy Act can also be found here.

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