Patient Enrollment Form

1

Overview
2

Patient Information
3

Patient Insurance
4

HCP Information
5

Eligibility & Documentation
6

Confirmation & Submit

3 Items You Will Need to Complete This Form:

Patient InformationIf applying for co-pay assistance or Celgene Patient Assistance Program (PAP), the patient’s gross family income and number of people living in their household will need to be provided.
Physician Information
Health Insurance Information (If Available)

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I am a...*

Please select all of the services you are looking for.

Benefits Investigation
Helps patients understand their insurance coverage and co-pays; assesses patient eligibility for Medicare, Medicaid, or alternative coverage
Celgene Commercial Co-pay Program
Assists patients who have commercial or private insurance but are unable to afford their co-pay
Prior Authorization/Precertification
Expedites the process of authorizing the use of a Celgene product prior to initiating therapy
Information on Independent Third-party Co-pay Assistance Organizations
Appeals Assistance
Helps appeal the denial of a prior authorization/pre-certification or claim for a Celgene product
Celgene Patient Assistance Program (PAP)
Fast Track for First Prescription®

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The following required fields have been left blank:

First Name*
Last Name*

Address Line 1*
Address Line 2 (Apt, Suite, etc.)

City*
State*

Zip Code*

Does the patient permanently reside in the US or a US territory?*

Yes

No

Phone Number*
— —
E-mail*

Gender*

Male

Female
Date of Birth*
— —

Social Security Number
— —
Marital Status

Drugs & Diagnosis

Drug*
Start Date
— —

Dosage
In Combination With (if applicable)

Number of Prior Therapies for This Diagnosis

Name(s) of Prior Therapies

Caregiver Information

First Name
Last Name

Contact Phone Number
— —
E-mail

Relationship to Patient

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The following required fields have been left blank:

*Does the patient have Health Insurance?

*Does the patient have Medicare?

*If the patient has Medicare, Please check all that apply
Part A

Part A (Hospital)

Part B

Part B (Medical)

Part D

Part D (Drug Coverage)

Medicare Advantage
I Don't Know

*Does the patient have Medicaid?

Insurance Company Information

Medical Insurance Company
Policy & Group Number

Name of Insured (Holder)
Plan Phone Number

Member ID Number
Healthcare Marketplace Plan

Prescription Coverage Information

Prescription Drug Plan Name
Policy & Group Number

Name of Insured (Holder)
Plan Phone Number

PCN Number
BIN Number

Other Insurance

Policy Name & Phone Number
Policy Number

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The following required fields have been left blank:

Physician Information

*First Name
*Last Name

DEA Number
NPI Number

Facility Information

*Facility Name
Tax ID Number

PTAN Number
Medicaid Provider Number

*Mailing Address Line 1
Mailing Address Line 2

*City
*State

*Zip Code

Contact First Name
Contact Last Name

Contact Title

*Phone Number
— —
E-mail

Preferred Method of Contact
Fax Number
— —

FAST TRACK FOR FIRST PRESCRIPTION^®

Revlimid^® (lenalidomide), Pomalyst^® (pomalidomide) and Thalomid^® (thalidomide) only

FAST TRACK FOR FIRST PRESCRIPTION^®

Yes

No

Please be sure to upload the patient's prescription (Rx) on the next screen or fax it to the Celgene Patient Support® team at 1-800-822-2496.

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The following required fields have been left blank:

You Are Almost Done

To submit this form, please read the user statement and agree to the terms. Finalize this form by entering your first and last name as your signature.

Protecting your confidential information is very important to us. All information provided to Celgene Patient Support^® will be encrypted and secured. If you have any questions regarding this electronic application, please call 1-800-931-8691.

User Confirmation Statement

I agree to the terms and conditions set forth above.*

First Name*
Last Name*

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Celgene Patient Support^® is committed to using our best efforts to protect your privacy. While the security of information in transit over the Internet cannot be assured, our privacy practices are designed to protect personally identifiable information and to ensure that we use information we receive in ways compatible with the purposes for which it has been collected. All the information provided in this online enrollment form will be sent in an encrypted form and then stored in a secure Celgene Database.

The information provided is for Celgene Patient Support^® use only and will not be shared outside of Celgene Patient Support^® and its authorized representatives, agents, and individuals or entities involved in processing this application and implementing a Celgene Patient Support^® program for which you may qualify. These may include your Healthcare Professional and health insurance provider. If you have questions about the privacy of your information, e-mail privacy@celgene.com or write to Celgene Corporation, 86 Morris Avenue, Summit, NJ 07901. Attention: Privacy Office.

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A Patient Support Specialist is Available to Help

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REVLIMID^® (lenalidomide), POMALYST^® (pomalidomide), and THALOMID^® (thalidomide) are only available through restricted distribution programs.

Please see full Prescribing Information, including Boxed WARNINGS, for REVLIMID^®, POMALYST^®, THALOMID^®, IDHIFA^® (enasidenib), and ABRAXANE^® for Injectable Suspension (paclitaxel protein-bound particles for injectable suspension) (albumin-bound). Please see full Prescribing Information for VIDAZA^® (azacitidine for injection).

3 Items You Will Need to Complete This Form:

Please select all of the services you are looking for.

Drugs & Diagnosis

Caregiver Information

Insurance Company Information

Prescription Coverage Information

Physician Information

Facility Information

Patient Financial Information

Documentation

Documentation Type

You Are Almost Done

User Confirmation Statement

A Patient Support Specialist is Available to Help