Endari

ENDARI Copay Assistance Registration

  • ELIGIBILITY QUESTIONS

  • PATIENT INFORMATION

  • PHYSICIAN INFORMATION

  • COVERAGE INFORMATION

  • PATIENT AUTHORIZATION

For assistance with this application, please contact our CPAP support services at copay@endarirx.com or at 1-855-723-5646.

Eligibility Questions

*REQUIRED FIELD

  • Patient must be a resident of the United States to be eligible for Endari® Copay Assistance.
*Are you a current resident of the United States, Puerto Rico, or US territories?
  • Endari® Copay Assistance is only available for patients that have commercial or private insurance.
*Do you have commercial or private insurance?
  • Patients covered by Medicare or any state or federally funded program are not eligible for Endari® Copay Assistance.
*Are you a Medicare beneficiary?
  • Patients covered by Medicare or any state or federally funded program are not eligible for Endari® Copay Assistance.
*Are your prescriptions paid for in part or in full under any state or federally funded program, including but not limited to Medicare or Medicaid, Medigap, VA, DOD, or TRICARE?
*Are you filling this form for a patient younger than 18 years of age?
  • Patients covered by Medicare or any state or federally funded program are not eligible for Endari® Copay Assistance.
*If at any time you begin receiving prescription benefits from a state, federal, or government-funded program at any time, you will no longer be eligible for the Endari Commercial Copayment Assistance Program. Do you understand and agree with this statement?

Parent or caretaker Information

*REQUIRED FIELD

*First name
*Last name
*Relationship to patient
Employer name
*Health insurance provider name
*Phone number
Email address

Patient Information

*REQUIRED FIELD

*First name
*Last name
*Gender
*Birthday
*Social Security Number
*Street address
*Country/Territory
*City and state
*Zip code
*Phone number
Email address

Physician Information

*REQUIRED FIELD

*Doctor's first name
*Doctor's last name
NPI
*Name of practice
*Phone number
Fax number
Street address
Country/Territory
City and state
Zip code
*Pharmacy name
*Pharmacy phone number
Pharmacy fax number
*Pharmacy contact
*Pharmacy street address
*Pharmacy country/territory
*Pharmacy city and state
*Pharmacy zip code

Coverage Information

*REQUIRED FIELD

*Please provide a copy of your Driver's License or State Issued Identification.
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*Please provide a copy of your Health Insurance and Pharmacy Benefit Card.
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*Reason for requesting financial assistance

Patient Authorization

*REQUIRED FIELD

Patient Consent to Share Certain Personal Health Information:

I hereby authorize pharmacy to use and/or disclose (release) my personal health information for the limited purpose of determining my eligibility for the Endari® Commercial Co-Payment Assistance Program. Such information will include: the date the prescription is filled, the number of pills or product dispensed by the pharmacy, and the amount of co-pay that will be paid for by using this program. This authorization will expire twelve (12) months after the date of signing of this form. I understand that by signing this authorization:

  • I authorize the use or disclosure of my individual identifiable health information as described above for the purpose listed. I understand that this authorization is voluntary.
  • I understand that this authorization may be revoked in writing at any time and is effective upon receipt. Written revocation will not affect any action taken in reliance on this authorization before the revocation is received.
  • I understand if the organization I have authorized to receive the information is not a health plan or health care provider; the released information may no longer be protected by federal privacy regulations.
  • I understand that I am signing this authorization voluntarily and that treatment, payment, or eligibility for my benefits will not be affected if I do not sign this authorization

*Patient signature
*Date

INDICATION

ENDARI [L-glutamine oral powder] is indicated to reduce the acute complications of sickle cell disease in adults and children 5 years and older.

IMPORTANT SAFETY INFORMATION

The most common side effects in clinical studies were constipation, nausea, headache, pain in the stomach area, cough, pain in the hands or feet, back pain, and chest pain.

Side effects that led to a stop in treatment during the clinical studies were 1 case each of overactive spleen (an organ that helps filter your blood), pain in the stomach area, indigestion, burning sensation and hot flash.

It is not known whether ENDARI is safe and effective in children younger than 5 years old with sickle cell disease.

Please see full Prescribing Information.

You are encouraged to report all possible negative side effects of ENDARI to Emmaus Medical, Inc. at 1-877-420-6493 or FDA at 1-800-FDA-1080 or www.fda.gov/medwatch.