Important instructions for completing pages 2 and 3 of the
Together with GSK Oncology Enrollment Form.
Patient Information
Prescriber Information
Next Steps:
Fax completed enrollment form to 1-800-645-9043. Together with GSK Oncology will confirm receipt with
healthcare professionals by the next business day and conduct a summary benefits call within 1-2 business
days regarding service options for patients. Patients will receive a call within 2 business days to be provided
with coverage information for their prescribed treatment and co-pay assistance options if eligible.
Section 1: Select the services you are requesting.
Section 2: Complete the Patient Information.
Section 4: If you’d like to receive Together with GSK Oncology updates via telephone or text
message, check the box to enroll.
Section 5: Read the HIPAA Patient Authorization on the last page, and then check the box,
sign, and date in section 5.
Section 6: (optional): If you’d like to see if you’re eligible for the Patient Assistance Program
(PAP), check the box to enroll, and complete PAP Information to research eligibility.
Section 7: (optional): If you’d like to enroll in the optional Patient Support Program, read the
content within section 7, then check the box, sign, and date.
Section 3: Provide the Prescriber/Facility Information.
Section 8: Include legible copies (front and back) of the patient’s medical and pharmacy insurance
card(s). Include primary, secondary, Medicare/Medicaid (if eligible), and pharmacy benefit insurance
information to ensure that ALL potential coverage options can be explored.
Section 9 (not required for enrollment in Quick Start or Bridge programs): Select your preferred
specialty pharmacy. If your preferred specialty pharmacy is not in GSK’s limited distribution network
or honored by the patient’s insurance plan, the benefits investigation will inform you of the approved
specialty pharmacy options available for your patient.
Section 10: Identify preferred shipping location if different than section 3.
Section 11: Diagnosis and appropriate ICD-10 code are required fields. For Quick Start or Bridge
program prescriptions, please complete section 11b or 11c, respectively. For all other prescriptions,
please complete section 11a.
Section 12: Read Prescriber Declaration, sign, and date. A healthcare professional’s signature is required.
Patient Name: ___________________________________ __________________________ Date of Birth: ___________ / ___________ / _______________
MM YYYYDD
❍ Patient’s Address (address from section 2)
❍ Other Address (eg, provider office)
Preferred Specialty Pharmacy (select one) Preferred Shipping Location (check one if shipping is needed)
Not required for enrollment in Quick Start or Bridge programs.
9 10
Recipient Name: ___________________________________________________________
Phone #: __________________________________________________________________
Street: ____________________________________________________________________
City: ______________________________________________________________________
State: _____________________________________ Zip: ___________________________
Preferred Specialty Pharmacy selection will be
honored if permitted by patient’s insurance plan.
❍ No preference
❍ In-office
dispensing site
❍ Biologics by McKesson
❍ Onco360 Oncology
Pharmacy
Treatment Start Date: _________ / _________ / _______________
Primary Diagnosis: ________________________________________ Primary Diagnosis ICD-10 Code: ____________ _____________________________
Secondary Diagnosis: _____________________________________ Secondary Diagnosis ICD-10 Code: _______ __________________________ _____
MM YYYYDD
REQUIRED: Prescriber Declaration
12
I certify that the information provided above is true and that OJJAARA is being prescribed for the patient listed above. I hereby certify
that, for any insured patient seeking co-pay assistance under the Co-pay Program, in the absence of financial support from such
program, any applicable co-pay, coinsurance, or other out-of-pocket cost for OJJAARA would be collected from the patient upon
treatment. I appoint Together with GSK Oncology, on my behalf, to convey this prescription to the dispensing pharmacy, to the extent
permitted under state law. Special Note: Prescribers in all states must follow applicable laws for a valid prescription. For prescribers in
states with official prescription form requirements, please submit an actual prescription along with this enrollment form. Prescribers may
need to submit an electronic prescription to the specialty pharmacy.
______________________________________________________________________________________________________________ Date: _____ / _____ / _______
SIGNATURE HERE
No stamps please.
MM YYYYDD
PRESCRIBER’S SIGNATURE
Page 3 of 4
Clinical Information
11
❍ Intermediate or high-risk primary myelofibrosis with anemia
❍ Intermediate or high-risk secondary myelofibrosis (post-polycythemia vera and post-essential thrombocythemia) with anemia
Previous Therapies: ____________________________________________________________________________________________________________
Latest Hemoglobin: ______________ g/dL Date of Last Transfusion: ❍ __________ / __________ / ______________ ❍ N/A
Known Drug Allergies: _________________________________________________________________________________________________________
Notes: _______________________________________________________________________________________________________________________
Current line of therapy:
Prescription
Medication Strength/Form Quantity Refills Directions for Administration
❍ 11a. OJJAARA: Standard Prescription
❍ 100 mg tablet
❍ 150 mg tablet
❍ 200 mg tablet
______ ______
❍ Take 1 tablet orally once daily with or
without food
❍ 11b. OJJAARA: Quick Start Program
For patients experiencing a delay in coverage
at first dispense
❍ 100 mg tablet
❍ 150 mg tablet
❍ 200 mg tablet
30 1
❍ Take 1 tablet orally once daily with or
without food
❍ 11c. OJJAARA: Bridge Program
For patients experiencing coverage
interruptions while already on treatment
❍ 100 mg tablet
❍ 150 mg tablet
❍ 200 mg tablet
30 1
❍ Take 1 tablet orally once daily with or
without food
Special Note: If a New York prescriber, please use an original New York State prescription form. The prescriber is to comply with the prescriber’s state-specific prescription requirements.
Prescriber’s Signature: _______________________________________
Date: _____________ / _____________ / _________________________
“Dispense As Written” / Brand Medically Necessary /
Do Not Substitute / No Substitution / DAW / May Not Substitute
Prescriber’s Signature: _______________________________________
Date: _____________ / _____________ / _________________________
May Substitute / Product Selection Permitted /
Substitution Permissible
SIGNATURE HERE SIGNATURE HERE
MM YYYYDD MM YYYYDD
Full Name: _____________________________________________________
Sex: ❍ Male ❍ Female Date of Birth: _____ _____ _________
Patient Address: _________________________________________________
City: __________________________________ State: ______ ZIP: ________
Home Phone #: _________________ Cell Phone #: ___________________
Email: __________________________________________________________
Patient Representative/Caregiver Name: _____________________________
Patient Representative/Caregiver Relationship to Patient: _______________
Patient Representative/Caregiver Phone #: ___________________________
Prescriber Name: ____________________________________________
Prescriber Title: ______________ Specialty: ______________________
NPI #: ______________________ Tax ID #: _______________________
Site/Facility Name: ___________________________________________
Mailing Address: _____________________________________________
City: ____________________________ State: _______ ZIP: _________
Office Contact Name: ________________________________________
Office Contact Phone #: _______________ Fax #: ________________
Office Contact Email: _________________________________________
Patient Information Prescriber/Facility Information
2 3
MM YYYYDD
Primary Insurance Payer: _____________________________________
Insurance Name: ______________________________________________
Phone #: ____________________ Policy ID #: _________________ ____
Group #: _____________________ PTAN#: ________________________
BIN: __________________________ PCN: _________________________
Policy Holder Name: ___________________________________________
Policy Holder Date of Birth: __________ / __________ / ______________
Policy Holder Relationship to Patient: ______________________________
Has a prior authorization (PA) been initiated? ❍ Yes ❍ No
If yes, PA status: ❍ Approved ❍ Denied ❍ Pending
Has an appeal been initiated? ❍ Yes ❍ No
If yes, PA status: ❍ Approved ❍ Denied ❍ Pending
Prescription Insurance Payer: _________________________________
Insurance Name: ___________ ___________________________________
Phone #: ____________________ Policy ID #: _____________________
Group #: _____________________ PTAN#: ________________________
BIN: __________________________ PCN: _________________________
Policy Holder Name: ___________________________________________
Policy Holder Date of Birth: __________ / __________ / _________ ____
Policy Holder Relationship to Patient: _________________________ ____
Insurance Information (check the relevant box)
Attach a copy of both sides of the patient’s insurance card(s).
8
❍ Medicare
❍ TRICARE
❍ Commercial/Private❍ Medicaid
❍ Uninsured
MM MMYYYY YYYYDD DD
❍ Other
❍ Medicare
❍ TRICARE
❍ Commercial/Private❍ Medicaid
❍ Uninsured❍ Other
Page 2 of 4
❍ Opt In
Texting Consent
(Rates May Apply)
4
By opting into texting you authorize GSK and its service providers to contact you and send communications about your enrollment in Together with
GSK Oncology via telephone and text message. These calls or text messages may be generated using auto-dial or pre-recorded messages at the
number you submit. The number and type of messages will be based upon your program selections, and message and data rates may apply. At
any time, you may request to stop telephone calls or text messages by following the opt-out directions provided during those communications.
Print Patient or Patient Representative Name: _______ __________ __________ ___ Relationship to Patient: _____________ __________ ________
5
❍ I have read and agree to the HIPAA Patient Authorization included on page 4 (required)
PATIENT OR PATIENT
REPRESENTATIVE TO SIGN
________________________________________________________________________________________________________________
PATIENT OR PATIENT REPRESENTATIVE SIGNATURE HERE
Patient Assistance Program (PAP) for uninsured and eligible Medicare patients
Patient Support Program (optional)
6
Check the services requested:
❍ Prior Authorization and Appeals Support
❍ Patient Advocacy Organization Information
❍ Patient Assistance Program
❍ Quick Start or Bridge Programs
❍ Benefits Investigation (Pharmacy and/or
Medical Insurance Coverage)
❍ Alternative Funding Sources Information
❍ Commercial Co-pay Assistance Program
1
7
Uninsured and eligible Medicare patients who are prescribed OJJAARA may be eligible for GSK’s Patient Assistance Program.
(Please note that this does not constitute health insurance.) To find out if you qualify, please fill in the information below.
❍ Enroll in PAP Program Annual pre-tax household income: ___________ Number of family members living in household: ___________
Medicare Beneficiary Identifier (MBI):
_________________________________
Applicants authorize the Together with GSK Oncology PAP and its Administrators to obtain a consumer report. The consumer report, and the information derived from public and
other sources, will be used to estimate income as part of the process to decide eligibility to receive free medication from GSK Oncology PAP. Upon request, GSK PAP will provide
applicants with the name and address of the consumer reporting agency that provides the consumer report. The program may request additional documents and information at
any time, even after enrollment, to determine if the information on the enrollment form is complete and true. Patients who participate or are enrolled in an Alternate Funding
Plan are not eligible for GSK PAP. For additional questions about eligibility, please contact the program or GSKforYOU.com.
❍ GSK believes your privacy is important. By providing your name, address, email address, and other information, you are giving GSK and companies working for
or with GSK permission to contact you for marketing, market research, or advertising purposes, or to invite you to interact with GSK in other ways across multiple
channels (eg, mail, email, websites, online advertising, applications, and services) regarding the medical condition(s) in which you have expressed an interest, as well
as other health-related information from GSK. GSK will not sell or transfer your name, address, or email address to any other party for their own marketing use. For
additional information regarding how GSK handles your information, please see our privacy notice at https://privacy.gsk.com/en-us/. 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.
Together with GSK Oncology support consent
Patient signature: ______________________________________________________________________________________ Date: _________________
I have read and agree to the OPTIONAL Together with GSK Oncology Support consent. For additional information regarding how GSK handles your information, please see
our privacy notice at https://privacy.gsk.com/en-us/.
Full Name: _____________________________________________________
Sex: ❍ Male ❍ Female Date of Birth: _____ _____ _________
Patient Address: _________________________________________________
City: __________________________________ State: ______ ZIP: ________
Home Phone #: _________________ Cell Phone #: ___________________
Email: __________________________________________________________
Patient Representative/Caregiver Name: _____________________________
Patient Representative/Caregiver Relationship to Patient: _______________
Patient Representative/Caregiver Phone #: ___________________________
Prescriber Name: ____________________________________________
Prescriber Title: ______________ Specialty: ______________________
NPI #: ______________________ Tax ID #: _______________________
Site/Facility Name: ___________________________________________
Mailing Address: _____________________________________________
City: ____________________________ State: _______ ZIP: _________
Office Contact Name: ________________________________________
Office Contact Phone #: _______________ Fax #: ________________
Office Contact Email: _________________________________________
Patient Information Prescriber/Facility Information
2 3
MM YYYYDD
Primary Insurance Payer: _____________________________________
Insurance Name: ______________________________________________
Phone #: ____________________ Policy ID #: _________________ ____
Group #: _____________________ PTAN#: ________________________
BIN: __________________________ PCN: _________________________
Policy Holder Name: ___________________________________________
Policy Holder Date of Birth: __________ / __________ / ______________
Policy Holder Relationship to Patient: ______________________________
Has a prior authorization (PA) been initiated? ❍ Yes ❍ No
If yes, PA status: ❍ Approved ❍ Denied ❍ Pending
Has an appeal been initiated? ❍ Yes ❍ No
If yes, PA status: ❍ Approved ❍ Denied ❍ Pending
Prescription Insurance Payer: _________________________________
Insurance Name: ___________ ___________________________________
Phone #: ____________________ Policy ID #: _____________________
Group #: _____________________ PTAN#: ________________________
BIN: __________________________ PCN: _________________________
Policy Holder Name: ___________________________________________
Policy Holder Date of Birth: __________ / __________ / _________ ____
Policy Holder Relationship to Patient: _________________________ ____
Insurance Information (check the relevant box)
Attach a copy of both sides of the patient’s insurance card(s).
8
❍ Medicare
❍ TRICARE
❍ Commercial/Private❍ Medicaid
❍ Uninsured
MM MMYYYY YYYYDD DD
❍ Other
❍ Medicare
❍ TRICARE
❍ Commercial/Private❍ Medicaid
❍ Uninsured❍ Other
Page 2 of 4
❍ Opt In
Texting Consent
(Rates May Apply)
4
By opting into texting you authorize GSK and its service providers to contact you and send communications about your enrollment in Together with
GSK Oncology via telephone and text message. These calls or text messages may be generated using auto-dial or pre-recorded messages at the
number you submit. The number and type of messages will be based upon your program selections, and message and data rates may apply. At
any time, you may request to stop telephone calls or text messages by following the opt-out directions provided during those communications.
Print Patient or Patient Representative Name: _______ __________ __________ ___ Relationship to Patient: _____________ __________ ________
5
❍ I have read and agree to the HIPAA Patient Authorization included on page 4 (required)
PATIENT OR PATIENT
REPRESENTATIVE TO SIGN
________________________________________________________________________________________________________________
PATIENT OR PATIENT REPRESENTATIVE SIGNATURE HERE
Patient Assistance Program (PAP) for uninsured and eligible Medicare patients
Patient Support Program (optional)
6
Check the services requested:
❍ Prior Authorization and Appeals Support
❍ Patient Advocacy Organization Information
❍ Patient Assistance Program
❍ Quick Start or Bridge Programs
❍ Benefits Investigation (Pharmacy and/or
Medical Insurance Coverage)
❍ Alternative Funding Sources Information
❍ Commercial Co-pay Assistance Program
1
7
Uninsured and eligible Medicare patients who are prescribed OJJAARA may be eligible for GSK’s Patient Assistance Program.
(Please note that this does not constitute health insurance.) To find out if you qualify, please fill in the information below.
❍ Enroll in PAP Program Annual pre-tax household income: ___________ Number of family members living in household: ___________
Medicare Beneficiary Identifier (MBI):
_________________________________
Applicants authorize the Together with GSK Oncology PAP and its Administrators to obtain a consumer report. The consumer report, and the information derived from public and
other sources, will be used to estimate income as part of the process to decide eligibility to receive free medication from GSK Oncology PAP. Upon request, GSK PAP will provide
applicants with the name and address of the consumer reporting agency that provides the consumer report. The program may request additional documents and information at
any time, even after enrollment, to determine if the information on the enrollment form is complete and true. Patients who participate or are enrolled in an Alternate Funding
Plan are not eligible for GSK PAP. For additional questions about eligibility, please contact the program or GSKforYOU.com.
❍ GSK believes your privacy is important. By providing your name, address, email address, and other information, you are giving GSK and companies working for
or with GSK permission to contact you for marketing, market research, or advertising purposes, or to invite you to interact with GSK in other ways across multiple
channels (eg, mail, email, websites, online advertising, applications, and services) regarding the medical condition(s) in which you have expressed an interest, as well
as other health-related information from GSK. GSK will not sell or transfer your name, address, or email address to any other party for their own marketing use. For
additional information regarding how GSK handles your information, please see our privacy notice at https://privacy.gsk.com/en-us/. 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.
Together with GSK Oncology support consent
Patient signature: ______________________________________________________________________________________ Date: _________________
I have read and agree to the OPTIONAL Together with GSK Oncology Support consent. For additional information regarding how GSK handles your information, please see
our privacy notice at https://privacy.gsk.com/en-us/.
Together with GSK Oncology Enrollment Form
Fax completed enrollment form to 1-800-645-9043
For assistance, please call 1-844-4GSK-ONC
Monday-Friday (8 AM to 8 PM ET)
Page 1 of 4
Please provide a signed copy of this form to the patient.
Visit us at www.TogetherwithGSKOncology.com
Full Name: _____________________________________________________
Sex: ❍ Male ❍ Female Date of Birth: _____ _____ _________
Patient Address: _________________________________________________
City: __________________________________ State: ______ ZIP: ________
Home Phone #: _________________ Cell Phone #: ___________________
Email: __________________________________________________________
Patient Representative/Caregiver Name: _____________________________
Patient Representative/Caregiver Relationship to Patient: _______________
Patient Representative/Caregiver Phone #: ___________________________
Prescriber Name: ____________________________________________
Prescriber Title: ______________ Specialty: ______________________
NPI #: ______________________ Tax ID #: _______________________
Site/Facility Name: ___________________________________________
Mailing Address: _____________________________________________
City: ____________________________ State: _______ ZIP: _________
Office Contact Name: ________________________________________
Office Contact Phone #: _______________ Fax #: ________________
Office Contact Email: _________________________________________
Patient Information Prescriber/Facility Information
2 3
MM YYYYDD
Primary Insurance Payer: _____________________________________
Insurance Name: ______________________________________________
Phone #: ____________________ Policy ID #: _____________________
Group #: _____________________ PTAN#: ________________________
BIN: __________________________ PCN: _________________________
Policy Holder Name: ___________________________________________
Policy Holder Date of Birth: __________ / __________ / ______________
Policy Holder Relationship to Patient: ______________________________
Has a prior authorization (PA) been initiated? ❍ Yes ❍ No
If yes, PA status: ❍ Approved ❍ Denied ❍ Pending
Has an appeal been initiated? ❍ Yes ❍ No
If yes, PA status: ❍ Approved ❍ Denied ❍ Pending
Prescription Insurance Payer: _________________________________
Insurance Name: ______________________________________________
Phone #: ____________________ Policy ID #: _____________________
Group #: _____________________ PTAN#: ________________________
BIN: __________________________ PCN: _________________________
Policy Holder Name: ___________________________________________
Policy Holder Date of Birth: __________ / __________ / _____________
Policy Holder Relationship to Patient: _____________________________
Insurance Information (check the relevant box)
Attach a copy of both sides of the patient’s insurance card(s).
8
❍ Medicare
❍ TRICARE
❍ Commercial/Private❍ Medicaid
❍ Uninsured
MM MMYYYY YYYYDD DD
❍ Other
❍ Medicare
❍ TRICARE
❍ Commercial/Private❍ Medicaid
❍ Uninsured❍ Other
Page 2 of 4
❍ Opt In
Texting Consent
(Rates May Apply)
4
By opting into texting you authorize GSK and its service providers to contact you and send communications about your enrollment in Together with
GSK Oncology via telephone and text message. These calls or text messages may be generated using auto-dial or pre-recorded messages at the
number you submit. The number and type of messages will be based upon your program selections, and message and data rates may apply. At
any time, you may request to stop telephone calls or text messages by following the opt-out directions provided during those communications.
Print Patient or Patient Representative Name: ______________________________ Relationship to Patient: _______________________________
5
❍ I have read and agree to the HIPAA Patient Authorization included on page 4 (required)
PATIENT OR PATIENT
REPRESENTATIVE TO SIGN
________________________________________________________________________________________________________________
PATIENT OR PATIENT REPRESENTATIVE SIGNATURE HERE
Patient Assistance Program (PAP) for uninsured and eligible Medicare patients
Patient Support Program (optional)
6
Check the services requested:
❍ Prior Authorization and Appeals Support
❍ Patient Advocacy Organization Information
❍ Patient Assistance Program
❍ Quick Start or Bridge Programs
❍ Benefits Investigation (Pharmacy and/or
Medical Insurance Coverage)
❍ Alternative Funding Sources Information
❍ Commercial Co-pay Assistance Program
1
7
Uninsured and eligible Medicare patients who are prescribed OJJAARA may be eligible for GSK’s Patient Assistance Program.
(Please note that this does not constitute health insurance.) To find out if you qualify, please fill in the information below.
❍ Enroll in PAP Program Annual pre-tax household income: ___________ Number of family members living in household: ___________
Medicare Beneficiary Identifier (MBI):
_________________________________
Applicants authorize the Together with GSK Oncology PAP and its Administrators to obtain a consumer report. The consumer report, and the information derived from public and
other sources, will be used to estimate income as part of the process to decide eligibility to receive free medication from GSK Oncology PAP. Upon request, GSK PAP will provide
applicants with the name and address of the consumer reporting agency that provides the consumer report. The program may request additional documents and information at
any time, even after enrollment, to determine if the information on the enrollment form is complete and true. Patients who participate or are enrolled in an Alternate Funding
Plan are not eligible for GSK PAP. For additional questions about eligibility, please contact the program or GSKforYOU.com.
❍ GSK believes your privacy is important. By providing your name, address, email address, and other information, you are giving GSK and companies working for
or with GSK permission to contact you for marketing, market research, or advertising purposes, or to invite you to interact with GSK in other ways across multiple
channels (eg, mail, email, websites, online advertising, applications, and services) regarding the medical condition(s) in which you have expressed an interest, as well
as other health-related information from GSK. GSK will not sell or transfer your name, address, or email address to any other party for their own marketing use. For
additional information regarding how GSK handles your information, please see our privacy notice at https://privacy.gsk.com/en-us/. 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.
Together with GSK Oncology support consent
Patient signature: ______________________________________________________________________________________ Date: _________________
I have read and agree to the OPTIONAL Together with GSK Oncology Support consent. For additional information regarding how GSK handles your information, please see
our privacy notice at https://privacy.gsk.com/en-us/.
Patient Name: _____________________________________________________________ Date of Birth: ___________ / ___________ / _______________
MM YYYYDD
❍ Patient’s Address (address from section 2)
❍ Other Address (eg, provider office)
Preferred Specialty Pharmacy (select one) Preferred Shipping Location (check one if shipping is needed)
Not required for enrollment in Quick Start or Bridge programs.
9 10
Recipient Name: ___________________________________________________________
Phone #: __________________________________________________________________
Street: ____________________________________________________________________
City: ______________________________________________________________________
State: _____________________________________ Zip: ___________________________
Preferred Specialty Pharmacy selection will be
honored if permitted by patient’s insurance plan.
❍ No preference
❍ In-office
dispensing site
❍ Biologics by McKesson
❍ Onco360 Oncology
Pharmacy
Treatment Start Date: _________ / _________ / _______________
Primary Diagnosis: ________________________________________ Primary Diagnosis ICD-10 Code: _________________________________________
Secondary Diagnosis: _____________________________________ Secondary Diagnosis ICD-10 Code: ______________________________________
MM YYYYDD
REQUIRED: Prescriber Declaration
12
I certify that the information provided above is true and that OJJAARA is being prescribed for the patient listed above. I hereby certify
that, for any insured patient seeking co-pay assistance under the Co-pay Program, in the absence of financial support from such
program, any applicable co-pay, coinsurance, or other out-of-pocket cost for OJJAARA would be collected from the patient upon
treatment. I appoint Together with GSK Oncology, on my behalf, to convey this prescription to the dispensing pharmacy, to the extent
permitted under state law. Special Note: Prescribers in all states must follow applicable laws for a valid prescription. For prescribers in
states with official prescription form requirements, please submit an actual prescription along with this enrollment form. Prescribers may
need to submit an electronic prescription to the specialty pharmacy.
______________________________________________________________________________________________________________ Date: _____ / _____ / _______
SIGNATURE HERE
No stamps please.
MM YYYYDD
PRESCRIBER’S SIGNATURE
Page 3 of 4
Clinical Information
11
❍ Intermediate or high-risk primary myelofibrosis with anemia
❍ Intermediate or high-risk secondary myelofibrosis (post-polycythemia vera and post-essential thrombocythemia) with anemia
Previous Therapies: ____________________________________________________________________________________________________________
Latest Hemoglobin: ______________ g/dL Date of Last Transfusion: ❍ __________ / __________ / ______________ ❍ N/A
Known Drug Allergies: _________________________________________________________________________________________________________
Notes: _______________________________________________________________________________________________________________________
Current line of therapy:
Prescription
Medication Strength/Form Quantity Refills Directions for Administration
❍ 11a. OJJAARA: Standard Prescription
❍ 100 mg tablet
❍ 150 mg tablet
❍ 200 mg tablet
______ ______
❍ Take 1 tablet orally once daily with or
without food
❍ 11b. OJJAARA: Quick Start Program
For patients experiencing a delay in coverage
at first dispense
❍ 100 mg tablet
❍ 150 mg tablet
❍ 200 mg tablet
30 1
❍ Take 1 tablet orally once daily with or
without food
❍ 11c. OJJAARA: Bridge Program
For patients experiencing coverage
interruptions while already on treatment
❍ 100 mg tablet
❍ 150 mg tablet
❍ 200 mg tablet
30 1
❍ Take 1 tablet orally once daily with or
without food
Special Note: If a New York prescriber, please use an original New York State prescription form. The prescriber is to comply with the prescriber’s state-specific prescription requirements.
Prescriber’s Signature: _______________________________________
Date: _____________ / _____________ / _________________________
“Dispense As Written” / Brand Medically Necessary /
Do Not Substitute / No Substitution / DAW / May Not Substitute
Prescriber’s Signature: _______________________________________
Date: _____________ / _____________ / _________________________
May Substitute / Product Selection Permitted /
Substitution Permissible
SIGNATURE HERE SIGNATURE HERE
MM YYYYDD MM YYYYDD
Page 4 of 4
REQUIRED: HIPAA Patient Authorization
By signing this form on page 2, I agree to allow my doctors, pharmacies, including my specialty
pharmacy(ies), and health insurers (collectively “Healthcare Providers”), to use and disclose my
health information to GSK and its agents, authorized representatives, and contractors (collectively
“GSK”) so that GSK can use and disclose my health information for purposes of providing
Together with GSK Oncology services, which may include the following activities:
1. Communicating with my Healthcare Providers about my OJJAARA prescription and medical
condition;
2. Investigating and resolving my insurance coverage, coding, or reimbursement inquiry, or
reviewing my eligibility for GSK’s patient assistance and co-pay assistance programs;
3. Contacting my insurer, other potential funding sources, and/or patient assistance programs on
my behalf to determine if I am eligible for health insurance coverage or other funds;
4. Contacting me to offer (and, if I am interested, provide) optional educational services offered by
healthcare professionals; and
5. Disclosing my information to third parties if required by law.
By signing this authorization, I acknowledge my understanding that:
• My Healthcare Providers will not and may not condition my treatment, payment for treatment, or
eligibility for or enrollment in benefits on whether I sign this patient authorization.
• Certain Healthcare Providers, such as specialty pharmacies, may receive payment from GSK for
disclosing my information to GSK as permitted by this authorization.
• Once information about me is released to GSK based on this authorization, federal privacy laws
may no longer protect my information and may not prevent GSK from further disclosing my
information. However, I understand that GSK has agreed to use or disclose information received
only for the purposes described in this authorization or as required by law.
• This authorization will remain in effect for two (2) years after I sign it (unless a shorter period is
required by state law) or for as long as I participate in the Together with GSK Oncology program,
whichever is longer. I have the right to receive a copy of this signed form over the time it is valid.
• I have the right to revoke this authorization at any time by mailing a signed written statement of
my revocation to Together with GSK Oncology, P.O. Box 5490, Louisville, KY 40255, but such
a revocation would end my eligibility to participate in the Together with GSK Oncology program.
Revoking this authorization will prohibit further disclosures by my Healthcare Providers based on
this authorization after the date a written revocation is received, but will not apply to the extent
that they have already taken action in reliance on this authorization. After this authorization is
revoked, I understand that information provided to GSK prior to the revocation may be disclosed
within GSK to maintain records of my participation.
The patient, or the patient’s authorized representative, MUST sign this form (section 5) in order for
the patient to receive Together with GSK Oncology services. If an authorized representative signs
for the patient, please indicate relationship to the patient.
Please provide a signed copy of this form to the patient.
Trademarks are owned by or licensed to the GSK group of companies.
©2024 GSK or licensor.
MMLBROC230001 January 2024
Produced in USA. 0002-0023-24