Supplemental Information for JYNARQUE® (tolvaptan)

Prescriber forms

JYNARQUE Prescription Process Checklist
A reminder of the steps to prescribe patients JYNARQUE.

Prescription Referral Form
You can e-prescribe or fax this completed form to one of the Specialty Pharmacies.

Quest Lab Account Setup Form
Set up an account with Quest Lab to facilitate compliance with JYNARQUE Risk Evaluation and Mitigation Strategy (REMS)-required lab work for your patients treated with JYNARQUE.

LabCorp Account Setup Form
Set up an account with Labcorp to facilitate compliance with REMS-required lab work for your patients treated with JYNARQUE.

JYNARQUE REMS Program Patient Status Form
Document the required monitoring for patients treated with JYNARQUE.

JYNARQUE Patient Tracker
Record your patients’ monitoring information.

Patient forms

Patient enrollment form
Sign patients up for the REMS program by completing the healthcare professional section first, then having patients fill out the rest. Submit the form either online at JYNARQUEREMS.com or by printing a paper copy that can be submitted by fax at 1-866-750-6820.

Lab Support Flashcard
Learn more about the Otsuka Laboratory Support Program. The program helps eligible patients get their REMS-required blood work done at no cost through a partnership with LabCorp and Quest Diagnostics.

Looking for more information about JYNARQUE?

To learn more about JYNARQUE and access more treatment resources, go to JYNARQUEhcp.com.

To learn more about the JYNARQUE REMS program or to access patient forms, go to JYNARQUEREMS.com.

Details and Eligibility

For patients:

In order to redeem this offer you must have a valid prescription for ABILIFY MAINTENA^® (aripiprazole). This offer may not be redeemed for cash. By using this offer, you are certifying that you meet the eligibility criteria (not a member of a federal, state, or government insurance program) and will comply with the terms and conditions described in the Restrictions section below. Patients with questions about the offer should call 1-888-591-9812.

Pharmacist:

When you use this card, you are certifying that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental programs for this prescription. As a condition of payment, you certify that you are in compliance with all program rules, terms, and conditions, as well as with any obligations to provide notice of your participation in this program to third-party payers as required by law, contract, or otherwise.

Submit the claim to the primary Third Party Payer first, then submit the balance due to Therapy First Plus as a Secondary Payer COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code (eg, 8). Eligible patients are responsible for as little as $10, with up to $8,000 in annual savings. A valid Prescriber ID# is required on the prescription. Reimbursement will be received from Therapy First Plus. For any questions regarding Therapy First Plus online processing, please call the Help Desk at 1-800-422-5604.

For healthcare professionals:

When you apply for this offer, you are certifying that you have not submitted a claim for reimbursement under any federal, state, or other governmental programs for this prescription. Participation in this program must comply with all applicable laws and regulations as a pharmacy provider. By participating in this program, you are certifying that you will comply with the terms and conditions described in the Restrictions section below.

Restrictions:

This offer is only valid in the United States and Puerto Rico and is not transferable. Patients are not eligible if they are under 18 years of age or are covered in whole or in part by any state program or federal healthcare program, including, but not limited to, Medicare or Medicaid (including Medicaid managed care), Medigap, VA, DOD, or TRICARE. Offer void where prohibited by law, taxed, or restricted. Other restrictions may apply. This program is not health insurance. Otsuka America Pharmaceutical, Inc. has the right to rescind, revoke, or amend this program at any time without notice. Your participation in this program confirms that this offer is consistent with your insurance coverage and that you will report the value received if required by your insurance provider. When you use this card, you are certifying that you understand and will comply with the program rules, terms, and conditions. Program managed by PSKW, LLC on behalf of Otsuka America Pharmaceutical, Inc. Offer not valid for cash-paying patients OR where drug is not covered by the primary insurance.

Please see U.S. FULL PRESCRIBING INFORMATION, including BOXED WARNING, AND MEDICATION GUIDE for ABILIFY MAINTENA.

JYNARQUE^®

(tolvaptan) tablets