Endari

ENDARI Support Program Registration

  • PROGRAM ELIGIBILITY

  • PATIENT INFORMATION

  • PRESCRIBER INFORMATION

  • PROGRAM INFORMATION

  • AUTHORIZATION AND CONSENT

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

Program Eligibility

*REQUIRED FIELD

  • Patient must be a resident of the United States to be eligible for Endari® Support Program.
*Are you a current resident of the United States, Puerto Rico, or US territories?
*Do you have commercial or private insurance?
  • Patients covered by Medicare or any state or federally funded program are not eligible for Endari® Support Program.
*Are you a Medicare beneficiary?
  • Patients covered by Medicare or any state or federally funded program are not eligible for Endari® Support Program.
*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?
  • Patients covered by Medicare or any state or federally funded program are not eligible for Endari® Program Support.
*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 Support Program. Do you understand and agree with this statement?
*Is this a New Application or a Re-enrollment Application?

Patient Information

*REQUIRED FIELD

*Full name
*Birthday
*Social Security Number
*Street address
*Country/Territory
*City and state
*Zip code
Home phone number
*Patient's cell phone number
Parent's cell phone number
*Patient/Parent email address

Prescriber Information

*REQUIRED FIELD

*Full name
*NPI
*Phone number
Fax number
*Street address
*Country/Territory
*City and state
*Zip code
*Email address
*Name of practice
*Office contact
*Office phone number

Program Information

*REQUIRED FIELD

Income Information
*Number of people in your household
*Number of dependents in your household under 18 years of age
*What is the total yearly combined household income before taxes?
(Include yourself, all adults, and all dependents)
*Please provide proof of income for all members in household (up to 4 documents).
A copy of federal tax returns preferred. Alternative acceptable documents are W-2 Forms, pay stubs, or Social Security Statements.
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Insurance Information
*Do you have any form of prescription drug coverage?
*Please provide a copy of the front and back of patient's insurance card (up to 2 documents).
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*Please provide a copy of your Driver's License or State Issued Identification.
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Authorization and Consent

*REQUIRED FIELD

CONSENT:

I GIVE my doctor, Emmaus Life Sciences, and the Program administrator and their employees, agents, and contractors permission to verify my information to make sure it is true and complete; contact me by mail or phone about the Program and about other products, programs, or services that might interest me or for which I may be eligible; contact me in order to ensure that I have received the medicines sent by the Program.

I ATTEST that all the information in this application, including all copies of documents proving my income, is true and complete; I am authorized to sign this application; I do not have any assistance or insurance that would help pay for my medicines; I am not enrolled in a Federal healthcare program; I will contact the Program if any of my information about my prescription drug coverage or insurance changes.

I UNDERSTAND that the Program will only use my information to decide if I qualify to participate in the Program; administer or improve the Program; communicate with insurance plans, including Medicare plans; share my information with the Centers for Medicare and Medicaid Services.

I UNDERSTAND that I may be required to apply for prescription assistance through a government assistance program to maintain eligibility in the Program.

I UNDERSTAND that I can call withdraw from the program at anytime.

I UNDERSTAND that the Program can request more information from me at any time; and ELS can change or stop the Program at any time or for any reason.

I UNDERSTAND that once my information has been disclosed to my doctor, federal privacy laws may no longer restrict its use or disclosure, but the Program will only use my information as described in this form.

I MAY refuse to sign this authorization form and I I refuse, my eligibility for health plan benefits and treatment by my healthcare provider will not change, but I will not have access to the Program.

I GIVE the Program, and the Program administrators, permission to contact the person named below with follow-up questions about my application (this only applies if someone completed this application for you). This authorization form will be effective for 1 year unless it expires earlier by law or I cancel it in writing. I have a right to receive a copy of this form after I have signed it.

I WILL notify Emmaus Life Sciences anytime there is a change in my insurance or prescription coverage.

*Relation to patient
*Name
*Relationship to Patient
Email or Phone
*Signature
*Date (MM/DD/YYYY)

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.