Please complete the form, sign, and FAX to 1-877-850-9901. For assistance, please call 1-877-423-6597 Monday – Friday, 8AM to 8PM ET.
ENROLLMENT FORM
Important instructions for completing the Benlysta Gateway Enrollment Form
Provide a signed copy of this form
to the patient
Fax completed enrollment form
to 1-877-850-9901 or submit
electronically to Benlysta Gateway
at www.BenlystaGatewayOnline.com
Step 2: Prescriber Information (Page 3)
Complete the Prescriber Information section
If place of administration differs from the prescribing ofce, complete the Site of Care section
Complete the Diagnosis Codes and Clinical Information Section
Step 4: Patient Consent and Signature (Page 2)
Return to Page 2 and
obtain the patient’s
signature. Please note:
• HIPAA Signature is
required
• BENLYSTA Cares
signature is optional
Step 3: Prescription Information (Page 4)
Next Steps
Complete the Prescription
Information section
Complete Prescriber
Signature
Step 1: Patient Information (Page 2)
Complete the Patient Information section
Complete the Insurance Information section
If requesting Patient Assistance Program, have the patient complete this section
This page intentionally left blank
Please complete the form, sign, and FAX to 1-877-850-9901. For assistance, please call 1-877-423-6597 Monday – Friday, 8AM to 8PM ET.
ENROLLMENT FORM
Patient Assistance Program (PAP): Patient to complete only if requesting PAP
Uninsured and eligible Medicare patients who are prescribed BENLYSTA may be eligible for GSK’s Patient Assistance Program (PAP).
To nd out if you qualify, please ll in the information below.
Annual pretax household income: Number of family members living in household:
Medicare Beneciary Identier (MBI):
Please note that this does not constitute health insurance. Applicants authorize the GSK Specialty 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 the GSK Specialty PAP. Upon request, the GSK Specialty 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. For additional
questions about eligibility, please contact the BENLYSTA Gateway.
*Insurance Information: Please provide front and back copies of all medical and prescription insurance cards
No insurance
Primary insurance Secondary insurance Pharmacy insurance
Insurance provider
Insurance phone
Cardholder name (if not the patient)
Cardholder DOB
Policy #
Group #
BIN/PCN N/A N/A
Benlysta Gateway Services
• Benets Verication and Prior Authorization Research
• Prior Authorization Follow-up and Appeal Support
• Co-pay Program (commercial only)
• Specialty Pharmacy (SP) Triage
• Patient Assistance Program (PAP)
• Claims and Billing Support
BENLYSTA Cares Support (Optional): Disease-specic education, patient
support services, and other communication
PATIENT SIGNATURE REQUIRED HERE Date:
I have read and agree to the HIPAA Patient Authorization form (please see page 6).*
PATIENT SIGNATURE HERE Date:
I have read and agree to the OPTIONAL BENLYSTA Cares Support consent (please see page 5).
If you have chosen to participate in the BENLYSTA Cares Program, please ll in your email on page 5.
©2023 GSK or licensor.
BELBROC230002 March 2023
Produced in USA. 0002-0023-57
Trademarks are owned by or licensed to the GSK group of companies.
Page 2 (submit to Gateway)
Patient Information *Indicates required elds
Last name*: First name*:
Street*: City*:
State*: Zip*: Email:
Date of birth* (mm/dd/yyyy): Gender: Language preference (if other than English):
Preferred phone #*:
Home Mobile Alternate contact name:
OK to leave a detailed voicemail?
Yes No Home/Mobile:
Preferred time to call:
Morning Afternoon Evening Alternate contact phone:
Alternate contact relationship to patient:
Enroll in Mobile Text
Notications (Optional):
Opt-in (include mobile phone
number above)
By opting into texting you authorize GSK and its service providers to contact you and send communications about your enrollment
in BENLYSTA Gateway 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 name: Relationship to patient:
Please complete the form, sign, and FAX to 1-877-850-9901. For assistance, please call 1-877-423-6597 Monday – Friday, 8AM to 8PM ET.
ENROLLMENT FORM
Prescriber, Acquisition, and Administration Information: Prescriber signature required
on all enrollment forms
*Indicates required elds
Prescriber’s last name*: Prescriber’s rst name*:
Practice name*: Specialty:
Street*:
City*: State*: Zip*:
Ofce contact name*: Phone*: Ext: Fax*:
Prescriber Tax ID*: State license #*:
Prescriber NPI #*:
Administration Method (choose one) Administration Site Acquisition Method
IV g Ofce administered only g Buy & bill g Specialty pharmacy
SC g Patient administered g Specialty pharmacy
I would like to understand coverage for all administration methods.
Site of Care: Complete this section ONLY if the place of administration
differs from the prescribing ofce
Administering practice/facility: Administering physician name:
Street address: City: State: Zip:
Phone: Ext: Fax:
Tax ID: NPI:
Check here if Gateway support is needed to identify an appropriate Site of Care (infusion center)
Diagnosis and Clinical Information
It is up to the provider to determine the most appropriate diagnosis code.
Consult the patient’s payer for coding or documentation requirements.
Diagnosis ICD-10 code*: Date of diagnosis (mm/dd/yyyy):
M32.10 Systemic lupus erythematosus, organ or system
involvement unspecied
Anti-nuclear antibody (ANA):
M32.8 Other forms of systemic lupus erythematosus Anti-ds DNA level:
M32.9 Systemic lupus erythematosus, unspecied SELENA-SLEDAI score: Patient weight:
M32.14 Glomerular disease in systemic lupus erythematosus Other:
M32.15 Tubulo-interstitial nephropathy in systemic lupus
erythematosus
Medication allergies:
Other:
Page 3 (submit to Gateway)
Please complete the form, sign, and FAX to 1-877-850-9901. For assistance, please call 1-877-423-6597 Monday – Friday, 8AM to 8PM ET.
ENROLLMENT FORM
• Prescriber signature below is required for Rx and/or enrollment • Specialty Pharmacy selection is subject to health plan requirements
New Restart Continuing
Last treatment date (mm/dd/yyyy):
Next treatment date/Date needed by (mm/dd/yyyy):
Has the prescription already been forwarded to a specialty pharmacy?
No Yes—which one?
Do not triage the prescription to the specialty pharmacy
PRESCRIBER SIGNATURE HERE
SUBSTITUTION PERMITTED (Date) DISPENSE AS WRITTEN* (Date)
Patient name: Date of birth (mm/dd/yyyy):
PRESCRIBER
TO SIGN
Prescription
Prescriber to indicate preferred dosing regimen of BENLYSTA
MEDICATION STRENGTH/FORM QTY REFILLS
DIRECTIONS FOR ADMINISTRATION
(prescriber to ll in)
Ofce Administered (IV)
BENLYSTA IV
120 mg in a 5-mL single-use vial (NDC
49401-101-01); reconstitute with 1.5 mL
Sterile Water for Injection, USP
400 mg in a 20-mL single-use vial (NDC
49401-102-01); reconstitute with 4.8 mL
Sterile Water for Injection, USP
Patient Administered (SC)
BENLYSTA SC
200 mg in a 1-mL single-dose autoinjector
(box of 4; NDC 49401-088-35)
200 mg in a 1-mL single-dose prelled
syringe (box of 4; NDC 49401-088-47)
Prescriber Declaration: I certify that the information provided above is true and that BENLYSTA 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 nancial
support from such program, any applicable co-pay, coinsurance, or other out-of-pocket cost for BENLYSTA would be
collected from the patient upon treatment. I appoint the BENLYSTA Gateway, 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 ofcial 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.
Page 4 (submit to Gateway)
ENROLLMENT FORM
What happens next?
1.
We contact your insurance
We will investigate your benets and help you understand your coverage options for
BENLYSTA. Typically, it takes about two business days for application processing.
2.
We will contact you
A representative will call you to help you understand your plan’s current coverage,
out-of-pocket costs, and financial assistance options (if eligible). A summary of this
benefit information will be sent to you and your healthcare provider. The information
provided by the Gateway is not a guarantee of coverage.
What’s next?
Look out for a phone call. You may not recognize the number, but it could be a call
about your prescription.
Call your doctor. If you don’t hear anything within the next two weeks, contact your
doctor’s office to check on the status of your prescription.
Optional: BENLYSTA Cares Support
3..
BENLYSTA Cares offers patient services to help you begin and continue treatment with
BENLYSTA. If enrolled, a healthcare professional* from the BENLYSTA Cares Nurse Support
Line will call you. The Support Line will get you on your way by answering questions you
may have about BENLYSTA.
Give them a call: 1-877-4-BENLYSTA (1-877-423-6597)
*BENLYSTA Cares personnel do not give medical advice. You will be directed to your
healthcare provider for any disease, treatment, or referral-related questions.
BENLYSTA Cares Support Consent:
By providing your name, address, email address, and other information including your
indication below 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.
My indication (select all that apply)
Lupus
Lupus nephritis
For additional information about how GSK handles your information, please see our
privacy notice at https://privacy.gsk.com/en-us.
Email address:
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.
Page 5 (submit to Gateway)
Questions? Call 1-877-4-BENLYSTA (1-877-423-6597).
Representatives are available Monday - Friday, 8AM to 8PM ET.
ENROLLMENT FORM
By signing this form, 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 GlaxoSmithKline and its agents, authorized representatives, and
contractors (collectively “GSK”) so that GSK can use and disclose my health information
for purposes of providing BENLYSTA Gateway services, which may include the following
activities:
1) Communicating with my Healthcare Providers about my BENLYSTA 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, eligibility for or enrollment in benets 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 BENLYSTA Gateway
Program, whichever is longer.
• I have the right to revoke this authorization at any time by mailing a signed written
statement of my revocation to P.O. Box 5490, Louisville, KY 40255, but that such a
revocation would end my eligibility to participate in the BENLYSTA Gateway program.
Revoking this authorization will prohibit further disclosures by my Healthcare Providers
based on this authorization after the date 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.
• I understand that I, as the patient or signer, have a right to receive a copy of this signed
form.
The patient, or the patient’s authorized representative, MUST sign this form to receive
BENLYSTA Gateway services. If an authorized representative signs for the patient, please
indicate relationship to the patient.
PATIENT AUTHORIZATION AND RELEASE TO COLLECT, USE, AND DISCLOSE HEALTH INFORMATION
Page 6 (provide to patient)
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