JazzCares | Xyrem 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 Authorization Form and enroll now to see if you are eligible for the JazzCares support services described below

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Personalized Resources, Nursing, and Pharmacy Support

Online Refill Scheduling

Never run out of your medication. Refilling your XYREM is easy and convenient with our online refill scheduling and reminder. Sign up to receive email and text reminders today. Call the pharmacy at 1-866-997-3688 to sign up!

Nursing Support

Your dedicated Nurse Case Manager assesses your unique needs, and can help you navigate social support, address practical challenges, and help motivate you!

Pharmacy Support

Through the Certified Pharmacy, a pharmacist is available 24/7 to answer questions about your prescription.

Savings and Support Programs

Coupon Program

Only pay as little as $35 for XYREM. A little support can make a big difference in staying on track with your treatment.

Terms and Conditions apply.

Quick Start Voucher

Are you waiting for your insurance to cover XYREM? You may be eligible to receive a free 1-month supply of XYREM with the Quick Start Voucher.

Terms and Conditions apply.

Bridge Program

Life can change quickly. Your treatment with XYREM may stay constant. The Bridge Program can provide eligible patients up to 4 months of XYREM for free.

Terms and Conditions apply.

Patient Assistance Program

JazzCares may have you covered, even if you do not have coverage. Enroll in the Patient Assistance Program as advised by the Certified Pharmacy.

ENROLL NOW

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

Terms and Conditions apply.

Terms and Conditions

Coupon Program

Eligible patients can pay as little as $35 for XYREM for a 30-day fill, subject to monthly and annual maximum benefit. The Coupon Program is only available for residents of the US, Puerto Rico, and the other US territories who have commercial insurance with out-of-pocket expenses, including co-pay/co-insurance/plan deductibles exceeding $35 (for XYREM) per 30-day prescription fill. The Coupon Program is for commercially insured patients that have been prescribed XYREM. The XYREM Coupon Program is not valid for beneficiaries of Medicare, Medicaid, VA, or other federal or state healthcare programs, if you pay for your prescription in cash or if you choose not to use your insurance coverage. The Coupon Program requires a valid, signed prescription for XYREM. The Coupon Program is for patients enrolled in the XYREM and XYREM REMS. The pharmacy will bill your insurance for the portion that your insurance plan has agreed to cover. The XYREM Coupon 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 any third party for any part of the benefit received by the patient through the Coupon Program. By using this offer, patients certify that they will comply with any terms of their health insurance contract requiring notification to their payor of the existence and/or value of this offer. It is illegal to (or offer to) sell, purchase, or trade this offer. This offer is non-transferrable. This offer is void where prohibited by law. No purchase necessary. The Coupon may not be applied retroactively. If your insurance changes, you must inform the pharmacy immediately. Based on your insurance change, you may no longer be able to participate in the XYREM Coupon Program. Jazz Pharmaceuticals reserves the right to terminate or modify this program at any time and without notice and in its sole discretion. In order to facilitate the XYREM Coupon Program, you understand and agree that Jazz will process your personal information in accordance to Jazz Pharmaceuticals' Privacy Policy which can be found at www.jazzcares.com.

Quick Start Voucher

The voucher is good for up to one-month’s free supply (maximum of three bottles) for a patient’s first-time shipment. There is a lifetime limit of one voucher per patient. The voucher is for commercially insured patients that have been prescribed XYREM for its FDA-approved indications. The voucher is only available for residents of the US, Puerto Rico, and the other US territories. The voucher is not valid for beneficiaries of Medicare, Medicaid, VA, or other federal or state healthcare programs. The voucher requires a valid, signed prescription for XYREM. The voucher is for patients enrolled in the XYREM and XYREM REMS. The voucher is for patients that are experiencing an insurance coverage decision delay greater than 10 calendar days for XYREM or for patients changing from XYREM who are at risk of therapy interruption (i.e., less than seven calendar days from the patient’s next XYREM delivery date). The voucher 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 voucher. The free supply of XYREM cannot be used toward any out-of-pocket costs under any health insurance or prescription drug plan. The voucher may not be applied retroactively and does not cover refills. The voucher cannot be combined with any other voucher, certificate, coupon, rebate, or similar offer. Use of the voucher is not contingent on any purchase requirement. This is not a discount, rebate, or insurance program. The voucher is not valid where otherwise prohibited by law. It is illegal for any person to sell, purchase, trade, or counterfeit the voucher. Jazz Pharmaceuticals reserves the right to terminate or modify this program any time with or without notice. In order to facilitate the XYREM Quick Start Voucher, you understand and agree that Jazz will process your personal information in accordance to Jazz Pharmaceuticals' Privacy Policy which can be found at www.jazzcares.com.

Bridge Program

The Bridge Program is for patients who have commercial insurance that are at risk of therapy interruption due to a change in insurance or change in insurance coverage for XYREM. The Bridge Program benefit is a free drug offer valid for up to a one hundred and twenty (120) day supply of XYREM or until commercial insurance coverage has been established or you have transitioned to a different therapy or discontinued therapy, whichever comes first, given in up to fifteen (15) day increments. The Bridge Program is only available for residents of the US, Puerto Rico, and the other US territories. The Bridge Program is for patients that have been prescribed XYREM for its FDA-approved indications. The Bridge Program is not valid for beneficiaries of Medicare, Medicaid, VA, or other federal or state healthcare programs, if you pay for your prescription in cash or if you choose not to use your insurance coverage. The Bridge Program requires a valid, signed prescription for XYREM. The Bridge Program is for patients enrolled in the XYREM and XYREM REMS. The Bridge 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 any third party for any part of the benefit received by the patient through the Bridge Program. It is illegal to (or offer to) sell, purchase, or trade this offer. This offer is non-transferrable. This offer is void where prohibited by law. No purchase necessary. If your insurance changes, you must inform the pharmacy immediately. Based on your insurance change, you may no longer be able to participate in the XYREM Bridge Program. Jazz Pharmaceuticals reserves the right to terminate or modify this program at any time and without notice and in its sole discretion.

Patient Assistance Program

Terms and Conditions apply.

Resources

JazzCares Patient Authorization Form:

In order to receive JazzCares services, please complete, sign, date, and mail the JazzCares Patient Authorization to the JazzCares Program, PO Box 66589, St. Louis, MO, 63166-6589

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Patient Assistance Program Application:

Complete, sign, date, and mail the Patient Assistance Program application to JazzCares Patient Assistance Program, PO Box 66589, St. Louis, MO, 63166-6589

Download

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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I. 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 enrolment;
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.

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, emailing customercare@jazzpharma.com or sending my request to: Jazz Pharmaceuticals, PO Box 66589, St. Louis, MO 63166-6589. 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://www.jazzpharma.com/privacy-statement/. 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: https://www.jazzpharma.com/privacy-statement/supplemental-notice-for-california-consumers/.

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 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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Personalized Resources, Nursing, and Pharmacy Support

Online Refill Scheduling

Nursing Support

Pharmacy Support

Savings and Support Programs

Coupon Program

Quick Start Voucher

Bridge Program

Patient Assistance Program

MEDICATION

Personal Information

INSURANCE

INCOME

MEDICAL EXPENSES

PROOF OF INCOME

Patient Assistance Program Application:

Terms and Conditions

Coupon Program

Quick Start Voucher

Bridge Program

Patient Assistance Program

Resources

JazzCares Patient Authorization Form:

Patient Assistance Program Application: