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. 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 or modify dose for hematologic toxicities.
- Mucositis may occur. If ≥Grade 2 mucositis is observed, omit or modify dose. Patients should be instructed to take folic acid and receive vitamin B12 to potentially reduce treatment-related hematological toxicity and mucositis.
- Fatal dermatologic reactions may occur. Dermatologic reactions may be progressive and increase in severity with further treatment. Patients with dermatologic reactions should be monitored closely, and if severe, FOLOTYN should be withheld or discontinued.
- Tumor lysis syndrome may occur. Monitor patients and treat if needed
- 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.
- Use caution and monitor patients when administering FOLOTYN to patients with moderate to severe renal function impairment.
- Elevated liver function test abnormalities may occur and require monitoring. If liver function test abnormalities are ≥Grade 3, omit or modify dose.
Adverse Reactions
- The most common adverse reactions were mucositis (70%), thrombocytopenia (41%), nausea (40%), and fatigue (36%). The most common serious adverse events are pyrexia, mucositis, sepsis, febrile neutropenia, dehydration, dyspnea, and thrombocytopenia.
Use in Specific Patient Population
- Nursing mothers should be advised to discontinue nursing or the drug, taking into consideration the importance of the drug to the mother.
Drug Interactions
- Co-administration of drugs subject to renal clearance (e.g., probenecid, NSAIDs, and trimethoprim/sulfamethoxazole) may result in delayed renal clearance.
