Patient Assistance Program
The ASAP program includes a patient assistance component that provides FOLOTYN free of charge to enrolled patients that meet the income, insurance, and citizenship/residency eligibility criteria.
FOLOTYN patients may enroll through their healthcare professional by completing the one-page ASAP enrollment form. Completed enrollment forms and required documentation may be faxed or mailed to the ASAP program at the following address:
Allos Support for Assisting Patients (ASAP)
6900 College Blvd.
Suite 1000
Overland Park, KS 66211
Phone: 1-877-ASAP102 (1-877-272-7102)
Fax: 1-877-801-0777
www.getASAPinfo.com
9:00am - 6:00pm ET
Download the ASAP Enrollment Form
Please include the following documentation when submitting the ASAP enrollment form:
- Medicaid Eligibility Denial Letter, or date on which patient applied for Medicaid (if applicable)
- Copies of medical and pharmacy insurance cards, front and back (if patient is insured)
- Copy of all denied claims, explanation of benefits, appeals letters and payer decision letters (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
- Three (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
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 with probenecid or other drugs that may affect relevant transporter systems (eg, NSAIDs), requires close monitoring for signs of systemic toxicity.
