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MEDICAL BENEFITS BILLING PORTAL FOR PROVIDERS. SITE-OF-CARE DRIVEN CO-PAY ASSISTANCE.

If your patient’s primary payer drug claim is billed under medical benefits, you can request Hizentra (Immune Globulin Subcutaneous [Human], 20% Liquid) co-pay assistance using this portal. Eligible patients can receive up to $5,000 per year to cover their out of pocket expenses.

Note: Nursing and supply costs that may be associated with the administration of the medication are not eligible for assistance through this program. For both medical and pharmacy benefits, claims must be received within 30 days of dispense date. For medical benefits only, EOBs must also be submitted within 120 days of the date the claim was submitted.


PATIENT ELIGIBILITY GUIDELINES FOR CO-PAY ASSISTANCE

  • Prescription must be for diagnosis of Primary Immunodeficiency (PI) or Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)
  • Patients must be at least 2 years of age if diagnosed with PI or at least 18 years of age if diagnosed with CIDP
  • Patient must be receiving Hizentra through a specialty pharmacy or physician office
  • It is recommended that the patient use a Specialty Pharmacy provider that is in network with the patient's current plan
  • Patient must express financial need
  • Patient must have coverage for the product under a private US insurance plan. Not valid for prescriptions eligible for reimbursement by any federal or state healthcare program, such as Medicare, Medicare advantage plans, Medicaid, PCIP, Champus, TriCare, Veterans Administration (VA), or any other state or federal program
  • Patients whose insurance policy prohibits co-pay assistance are not eligible*

  • * Prior to enrolling in this CSL Behring program, participants are responsible for checking with their insurance carrier to confirm that their participation is not inconsistent with their insurance carrier’s requirements.



This program is subject to change or discontinuation by CSL Behring at any time, for any reason, and with or without prior notice. This portal is administered by Medmonk for the Hizentra Co-Pay Relief Program.


Important Safety Information

WARNING: Thrombosis may occur with immune globulin products, including Hizentra. Risk factors may include: advanced age, prolonged immobilization, hypercoagulable conditions, history of venous or arterial thrombosis, use of estrogens, indwelling vascular catheters, hyperviscosity, and cardiovascular risk factors.

For patients at risk of thrombosis, administer Hizentra at the minimum dose and infusion rate practicable. Ensure adequate hydration in patients before administration. Monitor for signs and symptoms of thrombosis and assess blood viscosity in patients at risk for hyperviscosity.

Hizentra is contraindicated in patients with a history of anaphylactic or severe systemic reaction to human immune globulin (Ig) or components of Hizentra (eg, polysorbate 80), as well as in patients with immunoglobulin A deficiency with antibodies against IgA and a history of hypersensitivity. Because Hizentra contains L-proline as stabilizer, use in patients with hyperprolinemia is contraindicated.

IgA-deficient patients with anti-IgA antibodies are at greater risk of severe hypersensitivity and anaphylactic reactions. Thrombosis may occur following treatment with Ig products, including Hizentra.

Monitor patients for aseptic meningitis syndrome (AMS), which may occur following treatment with Ig products, including Hizentra. In patients at risk of acute renal failure, monitor renal function, including blood urea nitrogen, serum creatinine and urine output. In addition, monitor patients for clinical signs of hemolysis or pulmonary adverse reactions (eg, transfusion-related acute lung injury [TRALI]).

Hizentra is derived from human blood. The risk of transmission of infectious agents, including viruses and, theoretically, the Creutzfeldt-Jakob disease (CJD) agent and its variant (vCJD), cannot be completely eliminated.

The most common adverse reactions (observed in ≥5% of study subjects) were local infusion-site reactions, as well as headache, diarrhea, fatigue, back pain, nausea, extremity pain, cough, upper respiratory tract infection, rash, pruritus, vomiting, upper abdominal pain, migraine, arthralgia, pain, fall, and nasopharyngitis.

The passive transfer of antibodies can interfere with response to live virus vaccines and lead to misinterpretation of serologic test results.

Indications

Hizentra®, Immune Globulin Subcutaneous (Human), 20% Liquid, is indicated for:

For subcutaneous infusion only.

Please see full prescribing information for Hizentra including boxed warning.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.


Hizentra® is a registered trademark of CSL Behring AG.
Hizentra is manufactured by CSL Behring AG and distributed by CSL Behring LLC

HIZ-0468-APR18