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MONOFERRIC PATIENT SOLUTIONS PROGRAM


Rapid Response, Customized Solutions

The Monoferric Patient Solutions Program is committed to providing a seamless access journey to patients and healthcare providers.

Monoferric Patient Solutions Program™ Brochure
Download the Patient Solutions Program brochureProvides patients all the necessary information about what the program can offer them. Download PDF  

3 ways to enroll your patients

login
Log in to HCP Portal
call
Call us at 1‑800‑992‑9022
Monday to Friday, from 8 am to 8 pm ET
(except holidays)
download
Download and fax
enrollment form

Live and/or virtual reimbursement field and claims support

We provide rapid response and customized support

Representatives are available to help you navigate the steps to access product,
including prior authorizations, appeals, and reauthorizations.

Thumbs up icon Benefits verification/
investigation
Communications icon Claims & appeals assistance
Paper check icon Prior authorization
assistance
Telephone icon Case follow-up
Billing icon Buy and bill information
Support icon In-person HCP office support from
a local field reimbursement manager

To locate a Field Reimbursement Manager in your area:

Email: monoferricpatientsolutions
@pharmacosomos.us

Call: 1-800-992-9022

Billing and coding resources

Download the following resources for coding and coverage information
related to Monoferric (ferric derisomaltose)

Hospital outpatient billing and coding flashcard
Hospital outpatient billing
& coding flashcard
Download PDF  
Sample annotated UB-04
Sample annotated
UB-04
Download PDF  
HCP office billing and coding flashcard
Provider billing
& coding flashcard
Download PDF  
Sample annotated CMS-1500
Sample annotated
CMS-1500
Download PDF  
Sample letter of medical necessity
Sample letter of
medical necessity
Download PDF  
Sample letter of appeals
Sample letter
of appeals
Download PDF  

Copay and financial support

Pharmacosmos understands that each patient's financial circumstances are unique, which is why we offer copay assistance and other financial support to help them afford their treatment.

Monoferric Patient Solutions™ Copay Program Flashcard
Monoferric Patient Solutions
Copay Program flashcard
Download PDF  

ELIGIBILE PATIENTS PAY AS LITTLE AS

$0 per dose

To be eligible to participate in the Monoferric Patient Solutions Copay Program, patients must:

  • Have commercial health insurance (ie., health insurance offered through an employer; NOT Medicare, Medicare Advantage, Medicaid, TRICARE, or Veteran Affairs healthcare)
  • Reside in the United States or Puerto Rico
  • Be treated by a healthcare professional in the United States or Puerto Rico
  • Be 18 years of age or older
  • Be prescribed Monoferric for an on‑label diagnosis

If patients are eligible to participate:

  • They will receive savings on out-of-pocket expenses (i.e. deductible, copay or coinsurance obligations) for Monoferric of up to $1000 per dose
  • If IDA returns, a second dose may be covered and they would receive an annual maximum savings on out-of-pocket expenses of up to $2000 (on a total of 2 doses)§

*Maximum benefit of up to $1,000 per dose.

Cash paying patients may also qualify.

Only includes costs associated with Monoferric and does not apply to cost of administration.

§If patient's IDA returns in the same calendar year, Pharmacosmos Therapeutics Inc. will cover another product dose. Additional restrictions apply. Please see full Terms and Conditions.

The Monoferric Patient Solutions Patient Assistance Program

The Monoferric Patient Solutions Patient Assistance Program is available for people
who are under-insured or uninsured.

Patient Solutions

Eligibility Criteria

  • Fall within the income guidelines
  • Uninsured or under‑insured
  • Must be 18 years or older
  • Prescribed Monoferric for an on‑label diagnosis
  • Patient must be a resident of the United States (residency includes anyone who lives in one of the US states, the District of Columbia, Puerto Rico, and U.S. Virgin Islands). Citizenship or legal status is not a requirement.

Pharmacosmos Therapeutics Inc. and its authorized third-party agents will use the patient’s date of birth or social security number and/or additional demographic information as needed to access credit information and information derived from public and other sources to estimate income in conjunction with the eligibility determination process. As a soft credit inquiry, this option will not impact credit scores. Pharmacosmos Therapeutics Inc. and its authorized third-party agents reserve the right to ask for additional documents and information at any time. Please contact us for more information.

Supplemental nursing support

Online communication icon

Virtual live peer‑to‑peer nursing support,
in‑servicing, and on‑demand training

Supporting hand icon

Patient care support prior to infusion:

  • Provide alternate infusion site information
  • Referral to advocacy resources

Additional resources for starting patients on Monoferric

Monoferric Patient Brochure
Patient brochure Download PDF  
Monoferric Patient Solutions™ Program Brochure
Monoferric Patient Solutions
Program brochure
Download PDF  

Have questions or need support
over the phone?

Call us: 1-800-992-9022

Monday to Friday, from 8 am to 8 pm ET (except holidays)

Monoferric Patient Solutions Copay Program Terms and Conditions:

  • This offer is valid for commercially insured patients only; cash paying patients may also qualify
  • All information applicable to the Copay Assistance Program requested on the enrollment form must be provided and all certifications must be signed. Forms that are modified or do not contain all the necessary information will not be eligible for benefits under the Copay Assistance Program
  • Depending on insurance coverage, eligible patients receive savings of up to $1000 for Monoferric for the first dose and up to a maximum savings limit of $2000 annually (on a total of 2 doses). Patients must have out-of-pocket costs of over $0 to participate. Patient out-of-pocket expenses for Monoferric may vary
  • This offer is not valid for patients enrolled in Medicare, Medicare Advantage, Medicaid, TRICARE, Veteran Affairs health care, a state prescription drug assistance program, the Government Health Insurance Plan available in Puerto Rico (formerly known as “La Reforma de Salud”) or any other federal or state healthcare programs
  • Patients may not use the Copay Assistance Program if the entire cost of the patient’s Monoferric prescription is reimbursable by their commercial insurance plan or other commercial health or pharmacy benefit programs
  • The Copay Assistance Program is valid for the patient’s out-of-pocket cost for Monoferric only. It is not valid for any other out-of-pocket costs (for example, office visit charges or medication administration charges) even if such costs are associated with the administration of Monoferric. Claim for Monoferric must be submitted by provider to patient’s private health insurance separately from other services and products
  • The patient’s healthcare professional must submit an explanation of benefits (EOB) statement from the patient’s commercial insurance provider within 120 days of the date of service for the patient to receive assistance under the Copay Assistance Program. No EOB may be submitted more than 90 days after the expiration or [termination date of the program], and the EOB must be for administration of Monoferric prior to the program expiration or termination date. The EOB must reflect the patient’s out-of-pocket cost for Monoferric and submission of the claim by the patient’s physician for the cost of the medication
  • Patient enrollment is for the calendar year and each patient may reenroll in the Copay Assistance Program in subsequent years, as needed
  • The patient should not participate in the program if his/her insurer or health plan prohibits use of manufacturer coupons/copay assistance
  • Patients must be 18 years of age or older to participate in the Copay Assistance Program
  • Offer good only in the USA, including Puerto Rico, at participating pharmacies or healthcare providers
  • This patient savings under the Copay Assistance Program may not be combined with any other coupon, discount, prescription savings card, free trial, or other offer
  • Void if prohibited by law, taxed, or restricted
  • The funds provided for a specific patient case are not transferable. The selling, purchasing, trading, or counterfeiting of a patient’s unique account number is strictly prohibited
  • This program is not health insurance
  • This offer is not conditioned on any past or future purchases
  • Data related to your receipt of financial assistance under the Copay Assistance Program may be collected, analyzed, and shared with Pharmacosmos, for market research and other purposes related to assessing Pharmacosmos’s programs. Data shared with Pharmacosmos will be aggregated and deidentified; it will be combined with data related to other program use and will not identify you
  • Pharmacosmos Therapeutics Inc. reserves the right to rescind, revoke, or amend this offer without notice
  • By redeeming this assistance, you acknowledge that you are an eligible patient and that you understand and agree to comply with the terms and conditions of this offer
  • Qualified patients receiving Monoferric will be allowed a 120-day retroactive enrollment period to receive benefits under the program rules