Support for You and Your Patients
CINQAIR Cost Support Program
CINQAIR
Cost Support Program
1-844-838-2211
Monday – Friday
8 am – 8 pm ET
$ 0
Medication costs per dose
Administration costs
per treatment
The CINQAIR® Cost Support Program helps eligible, commercially insured individuals pay out-of-pocket medication and administration costs, including co-insurance, co-pays, and deductibles.
The CINQAIR® Cost Support Program is available to eligible patients who have been prescribed CINQAIR and have commercial prescription insurance. This program is intended for the benefit of patients, not their insurance plans or other third parties. Maximum program assistance per prescription and annual benefit limits per individual apply and out-of-pocket expenses may vary.
Patient is responsible for costs above maximum benefit amounts. This program is restricted to residents of the United States and United States territories, subject to applicable law. Uninsured and cash-paying patients are NOT eligible for this program. Patients enrolled in any state or federally funded healthcare program, including but not limited to, Medicare, Medigap, Medicaid, VA, DOD, TRICARE, Puerto Rico Government Health Insurance Plan, Medicare-eligible patients enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees, are NOT eligible for this program.
Teva Respiratory, LLC and its affiliates reserve the right to change, rescind, revoke, or discontinue this program at any time without notice. Please see complete Terms and Conditions at CINQAIRTandC.com
How to use the Cost Support Program Copay Card
Eligible patients use the Cost Support Program Card to help pay out-of-pocket costs for treatment with CINQAIR® at their infusion treatment provider.
Here’s how the CINQAIR® Cost Support Program works:
To the Pharmacist:
By redeeming this Copay Card, you are certifying that you understand and agree to comply with the Terms and Conditions listed herein. When you apply this offer, you are certifying that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental program for this prescription. Submit claim to PDMI. If primary coverage exists, input offer information as secondary coverage and transmit using the COB segment of the NCPDP transaction. For questions, please call the Paysign Help Desk at 1-844-838-2211
To the Prescriber:
By redeeming this Copay Card, you are certifying that you understand and agree to comply with the Terms and Conditions listed herein. When you apply this offer, you are certifying that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental program for this prescription. All claim submissions must include a copy of the Explanation of Benefits and a copy of the claim form (CMS-1500, UB04, or electronic equivalent). Claims may be submitted by one of the below methods:
Electronic submission to PAYOR ID PSN22
Fax:
1-844-838-2213
Mail to:
CINQAIR Cost Support Program
PO Box 530492
Henderson, NV 89053
Patients use the CINQAIR® Cost Support Program Card to pay out-of-pocket costs for treatment with CINQAIR®.
Codes for CINQAIR
The following codes are commonly used to communicate services rendered when filing claims for CINQAIR. Codes for CINQAIR may vary by payer or site of care.*
|
ICD-10 CODES |
You should select the appropriate diagnosis code based on your clinical diagnosis. If you have questions about coverage for certain diagnosis codes, please contact the patient’s insurance plan. |
|
NDC CODES |
NATIONAL DRUG CODE 59310-610-31 (FDA 5-3-2 Format) When filing a claim, you may need to add a zero (0) on the claim form as follows: 59310-0>610-31. NOTE: Do not include hyphens (-) on the claim form. |
|
HCPCS CODES |
MEDICATION LEVEL II J2786 Injection, reslizumab, 1 mg |
|
CPT® CODES |
INFUSION ADMINISTRATION 96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug HOME INFUSION 99601 Home infusion/specialty drug administration, per visit (up to 2 hours) |
* Providers are responsible for the accuracy of any claims, invoices, or related documentation submitted to payers. Contact your payer for specific guidance.
Acquiring CINQAIR
CINQAIR® can be ordered from one of our Authorized Specialty Distributors (Buy & Bill) or, subject to a patient’s health plan requirements, CINQAIR® may also be acquired from a specialty pharmacy.
Buy & Bill
These Authorized Speciality Distributors are the exclusive suppliers of CINQAIR®.
CuraScript SD
Phone: 1-877-599-7748
Fax: 1-866-628-8942
Metro Medical A Cardinal Health company
Phone: 1-800-768-2002
Fax: 1-615-256-4194
Contact the individual specialty distributor for current pricing.
Speciality Pharmacy
Providers preferring to acquire CINQAIR® via specialty pharmacy, or if the patient’s health plan requires, CINQAIR® can be acquired though a specialty pharmacy. Check with the patient’s health plan to confirm specialty pharmacy requirements.
Teva Cares Foundation
For patients who are uninsured or unable to afford CINQAIR, the Teva Cares Foundation may be able to help.
Teva Cares is an independent, non-profit program that provides CINQAIR at no cost to eligible patients*. To learn more visit TevaCares.org or call 1-877-237-4881.
*Patient must reside in the United States, meet insurance and income requirements, and have a valid prescription.