ASAP Enrollment form checklist

6900 College Blvd. Ste 1000 • Overland Park, KS 66211
Phone: 1-877-ASAP102 (1-877-272-7102) • Fax: 1-877-801-0777

Please ensure that the application is fully completed and that all supporting documentation is included. Incomplete or missing documentation may result in delays in processing the application.

Please include the following documentation when submitting this application for consideration into the ASAP program:

  • Medicaid Eligibility Denial Letter, or date on which patient applied for Medicaid
  • Copies of insurance cards, front and back (if patient is insured)
  • Copy of unfavorable decision letter from final level of appeal (if patient is insured)
  • Proof of Gross Annual Household Income in one of the forms listed below:
    • Previous year’s W-2 or tax return
    • 3 months of checking account statements showing amount
      of income deposited and the company depositing the income
    • A full month’s worth of pay stubs
    • Social Security benefit award letter or check
    • If patient has no income
      • A notarized letter from the family stating that patient has zero income with an explanation of how patient is supported
      • A signed zero income letter from the physician, including an explanation of how patient is supported, on the physician’s letterhead

You can download the ASAP Enrollment Form here.

You may fax the application to 1-877-801-0777 or mail it to:

Allos Support for Assisting Patients
c/o AccessMED, Inc.
6900 College Blvd. Ste 1000
Overland Park, KS 66211

Please call 1-877-ASAP102 (1-877-272-7102) if you have any questions regarding the application or the ASAP program.

Thank you,

ASAP Reimbursement Counselor

Allos Therapeutics, Inc. does not guarantee coverage and/or reimbursement for FOLOTYN (pralatrexate injection). Coverage, coding, and reimbursement policies vary significantly by payer, patient, and setting of care. Actual coverage and reimbursement decisions are made by individual payers following the receipt of claims. Allos strongly recommends verifying coverage, coding, and reimbursement guidelines on a payer and patient-specific basis.


IMPORTANT SAFETY INFORMATION

Warnings and Precautions

  • FOLOTYN may suppress bone marrow function, manifested by thrombocytopenia, neutropenia, and anemia. Monitor blood counts and omit and/or reduce dose for hematologic toxicities.
  • Mucositis may occur. Monitor at least weekly. If ≥Grade 2 mucositis is observed, omit and/or reduce dose. Patients should be instructed to take folic acid and receive vitamin B12 to potentially reduce treatment-related hematological toxicity and mucositis.
  • Dermatologic reactions, including fatal reactions, have occurred and may be progressive and increase in severity with further treatment. Patients with dermatologic reactions should be monitored closely, and omit, and/or reduce dose or discontinue FOLOTYN.
  • Tumor lysis syndrome may occur. Monitor patients and treat promptly.
  • FOLOTYN can cause hepatic toxicity and liver function test abnormalities. Monitor liver function tests and if abnormalities are ≥Grade 3, omit until recovery then reduce dose or discontinue FOLOTYN as required.
  • Patients with moderate to severe renal function impairment may be at greater risk for increased exposure and toxicity. Monitor patients for renal function and systemic toxicity and adjust dosing accordingly. Avoid FOLOTYN use in patients with end stage renal disease including those undergoing dialysis unless the potential benefit justifies the potential risk.
  • FOLOTYN can cause fetal harm. Women should avoid becoming pregnant while being treated with FOLOTYN and pregnant women should be informed of the potential harm to the fetus.

Adverse Reactions

  • The most common adverse reactions were mucositis (70%), thrombocytopenia (41%), nausea (40%), and fatigue (36%). The most common serious adverse events were pyrexia, mucositis, sepsis, febrile neutropenia, dehydration, dyspnea, and thrombocytopenia.

Drug Interactions

  • Co-administration with probenecid or other drugs that may affect relevant transporter systems (eg, NSAIDs), requires close monitoring for signs of systemic toxicity.

Use in Specific Populations

  • Nursing mothers should be advised to discontinue nursing or the drug, taking into consideration the importance of the drug to the mother.
  • Approximately one third of the administered dose of FOLOTYN is cleared by the kidneys. FOLOTYN has not been studied in patients with renal impairment.

Please see FOLOTYN Full Prescribing Information