HELPING PATIENTS
GAIN ACCESS TO REBYOTA^®

Diagnosis

International Classification of Diseases, ICD-10 diagnosis codes
ICD-10 codes are an alphanumeric coding system used to report patient conditions, illnesses, or symptoms, which support medical necessity for healthcare services.

Administration

Current Procedural Terminology, CPT codes
CPT codes are a numeric coding system used to report medical services and procedures related to the administration of a drug or product, as provided by healthcare professionals.

Product Code

Healthcare Common Procedure Coding System (HCPCS)
Each infused drug, or non-oral, non-self-administered drug that may be used in the inpatient, outpatient, hospital, doctor’s office, or infusion center, is assigned a code to facilitate medical billing.

Commercially insured PATIENTS MAY PAY AS LITTLE AS $100 for each REBYOTA prescription.^a

The Program is open to patients who meet the following eligibility criteria:

• For commercially insured individuals whose insurance plans cover REBYOTA
• Must be 18 years of age or older
• Offer valid only in the US
• Must have been administered REBYOTA for an FDA-approved indication

See additional terms and conditions below.

Please provide your patients with guidance on how they may enroll in the REBYOTA Co-pay Program. For additional assistance, call 1-877-REBYOTA.

^aAvailable only for patients who meet eligibility requirements. Program does not cover the cost of administration, office visits, or any associated costs. Terms and conditions apply. Offer expires 12/31/24.

Healthcare Provider Instructions:

Healthcare Providers: If purchasing REBYOTA using standard Buy & Bill processes, you may enroll your patients in the REBYOTA Co-pay Program in one of two ways:

• By first enrolling your patient in the REBYOTA Connect Program, a Program Case Manager will complete a full benefits investigation to understand your patient’s insurance coverage for REBYOTA, as well as screen your patient for eligibility in the co-pay program and other forms of financial assistance. To enroll patients in REBYOTA Connect visit www.REBYOTACONNECT.com or call 1-877-REBYOTA.
• If an eligible patient does not wish to enroll in the REBYOTA Connect Program, they can access the REBYOTA Co-pay Program if your office uses our online portal at www.HCP.REBYOTACopay.com.

Specialty Pharmacy Instructions:

Specialty Pharmacies: If your patient is enrolled in the REBYOTA Connect Program, you will be provided with information on how to access the REBYOTA Co-pay Program when the prescription is triaged to you from the Program. If an eligible patient is not enrolled in the REBYOTA Connect Program, they can still receive access to the REBYOTA Co-pay program by using our online portal at www.SP.REBYOTACopay.com.

TERMS AND CONDITIONS

This offer is not contingent on any past, present or future purchase, including refills. REBYOTA Co-pay Program (“Program”) offer is good for use only upon the administration of REBYOTA (“Product”) for an FDA-approved indication in the US (including DC) or the Commonwealth of Puerto Rico. The value of this program is exclusively for the benefit of patients and is intended to be credited toward patient out-of-pocket obligations for REBYOTA including applicable co‑payments, coinsurance, and deductibles. Ferring will provide coverage maximum cap of up to $5,000 per dose with a maximum benefit of $10,000 per patient per calendar year. The value of this offer may not exceed the amount of the patient’s out-of-pocket costs for the Product. Documentation including Explanation of Benefits (EOB) will be required. The Program is not health insurance. Offer is invalid for all transactions and claims submitted more than 180 days following the date of service. The Program is not valid for Product reimbursed in whole or in part by Medicare, Medicaid, or a Medicare Part D plan, TRICARE, US Department of Veteran Affairs, US Department of Defense, the Commonwealth of Puerto Rico, government health insurance plan, or any other federal or state-funded healthcare benefit program. The Program is void where prohibited by law, taxed, or restricted, as in the States of California and Massachusetts. The Program is not transferable and is limited to one program benefit per patient. No substitutions are permitted. The Program benefit cannot be combined with any other co-pay program, free trial, discount, prescription savings card, or other offer. Patients, pharmacists, and prescribers cannot seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this offer. Ferring Pharmaceuticals reserves the right to rescind, revoke, or amend this offer without notice. Offer expires 12/31/24.

Program Information & Eligibility Requirements:

Your patients may be eligible to receive REBYOTA^® (fecal microbiota, live – jslm) at no cost if they qualify for the Ferring REBYOTA Patient Assistance Program (PAP).

The program is open to uninsured and underinsured patients who meet the following eligibility criteria:

• Must be prescribed REBYOTA for an FDA-approved indication
• Reside in the United States
• Are being treated by a US-licensed healthcare provider
• You must have a household income at or below 500% of the Federal Poverty Level, adjusted for family size

Healthcare Provider Instructions:

Healthcare Providers: To have your patient screened for assistance through the REBYOTA Patient Assistance Program, visit www.REBYOTACONNECT.com to enroll or fax a completed and signed form that can be found by downloading this form to 1-877-778-7167.

*Section 3 of the REBYOTA Connect Hub Enrollment Form must be completed in addition to all other required sections and signatures.

TERMS AND CONDITIONS

• The REBYOTA Patient Assistance Program (“PAP”) is only available for qualified patients enrolled in REBYOTA Connect.
• Participation in the PAP is free. Ferring does not collect any fees from people seeking assistance through PAP.
• Assistance is provided in the form of free product shipped to site of administration or reimbursement for the invoiced cost of the product if processed after product has been administered. If assistance is in the form of free product, REBYOTA must be secured at the site of administration until the qualified PAP patient’s treatment date, and the medicine must be provided only to the eligible patient at no charge of any kind for the product. If product administration occurs and patient was qualified for PAP, reimbursement for the invoiced cost of the product can occur for Healthcare providers or Specialty Pharmacies after they have provided supporting documentation for the product cost only in addition to a completed Reimbursement Request form. PAP only covers the cost of the product and not administration or other services.
• Any medications supplied by Ferring as a result of enrollment in the PAP are for the use of the named patient only and will not be sold, traded, bartered, transferred, returned for credit, or submitted to any third party (such as Medicare, Medicaid, or other benefit provider) for reimbursement.
• If REBYOTA is no longer medically necessary for a qualified patient’s treatment or if the patient’s insurance or financial status changes, this must be reported to REBYOTA Connect.
• Electronic verification of a patient’s financial status is available to help determine eligibility.
• PAP beneficiaries with government insurance are eligible to obtain medication through the end of the calendar year. PAP beneficiaries with commercial insurance are eligible to obtain medication for up to 12 months.
• Healthcare Providers may not submit claims or payment from this medication through an insurance plan of any kind. Patients may not seek true out-of-pocket (TrOOP) or other insurance credit for medication provided through the PAP.
• If applicable, PAP recipients will have their health plans receive written notification.
• Ferring may change or cancel the PAP at any time and Ferring reserves the right to terminate a patient’s enrollment in the PAP at any time.

Drugs: Medicare Part B, which covers outpatient physician services, pays for physician-administered drugs. The payment methodology for REBYOTA is expected to be based on its average sales price (ASP) plus 6% during sequestration. Note that Medicare’s drug and product payment rates change on a quarterly basis. Consult the Centers for Medicare & Medicaid Services (CMS) website for the latest Medicare information at https://www.cms.gov/medicare/payment/all-fee-service-providers/medicare-part-b-drug-average-sales-price/asp-pricing-files.¹

Procedures: The Medicare Physician Fee Schedule (MPFS) is a master list of reimbursement rates and is the primary guideline for payment for enrolled healthcare professionals. The MPFS is updated on a quarterly basis to reflect the most recent changes to reimbursement rates. A Physician Fee Schedule Guide can be found at https://www.cms.gov/files/document/physician-fee-schedule-guide.pdf. Use code G0455 as directed by CMS.

^aPlease see table of codes in REBYOTA coding and billing.

Drugs: State Medicaid programs have different payment rates when administered in the physician office setting. Medicaid payment may be based on state-specific fee schedules. In the physician office setting, REBYOTA may be reimbursed based on methodologies such as a percentage of ASP, wholesale acquisition cost (WAC), or invoice price. Medicaid may require providers to submit product invoices for reimbursement. Drug reimbursement is updated quarterly, by state, and is available at Medicaid.gov.²

Procedures: States may offer Medicaid benefits on a fee-for-service (FFS) basis, through managed care plans, or both. Under the FFS model, the state pays providers directly for each covered service received by a Medicaid beneficiary. Under managed care, the state pays a fee to a managed care plan for each person enrolled in the plan. In turn, the plan pays providers for all of the Medicaid services a beneficiary may require that are included in the plan’s contract with the state.³

^aPlease see table of codes in REBYOTA coding and billing.

Drugs and procedures: Private payers vary in payment rates. Often, they are based on payer/institution contracted rates. For each patient, cost-sharing requirements, such as coinsurance and annual deductible amounts, will vary by individual insurance plan. Consult the patient’s plan for details by running a benefits verification.

^aPlease see table of codes in REBYOTA coding and billing.