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enroll in IMBRUVICA® patient support

Welcome to IMBRUVICA® By Your Side, a comprehensive, personalized support experience designed to help IMBRUVICA® patients start and stay on track with the treatment plan you prescribed.

IMBRUVICA® By Your Side provides:

Comprehensive Resources

Dedicated Ambassadors

Financial Guidance

Complete this form with the permission of your patient to enroll them in IMBRUVICA® By Your Side, so they can get the support they need throughout their treatment journey.

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Prescriber Information

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Patient Details

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Insurance Information

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Enrollment Complete

Prescriber Information

Office Location

Office Contact Information

For information on how Pharmacyclics and Janssen handle personal information, please visit their privacy notices at https://www.pharmacyclics.com/privacy-policy.

Patient Details

Please enter the following information to successfully enroll your patient in IMBRUVICA® By Your Side. Be advised that the form MUST be filled out properly, so that your patient has the best experience in the program.

All fields are required unless otherwise noted

Contact Information

Caregiver Information (Optional)

For information on how Pharmacyclics and Janssen handle personal information, please visit their privacy notices at https://www.pharmacyclics.com/privacy-policy.

Insurance Information

IMBRUVICA® By Your Side patient support offers financial guidance for enrolled patients, including a copay card for eligible patients with commercial insurance.

Type of Insurance

With IMBRUVICA® By Your Side, your patient with commercial insurance may be eligible for the IMBRUVICA® Copay Card. Once your patient is successfully enrolled, they will immediately receive the copay card and a call within one business day from their dedicated By Your Side Ambassador.

Please enter patient’s Rx insurance information

This includes Medicare Part D, Medicare Advantage Plan, Medicaid, TRICARE, or any other federal or state healthcare plan, including pharmaceutical assistance programs

IMBRUVICA® By Your Side Ambassadors can connect your patients with Insurance Specialists who will work with them to review financial support options and confirm their out-of-pocket costs for IMBRUVICA® patients.

IMBRUVICA® By Your Side Ambassadors can connect your patients with Insurance Specialists who will review financial support options and confirm their out-of-pocket costs for IMBRUVICA®.

IMBRUVICA® By Your Side Ambassadors can help your patients learn about potential resources to help them with affording IMBRUVICA®

*Privately purchased insurance or insurance made available through an employer.

Prescriber Certification

Benefits Verification

Benefits verifications are performed by the IMBRUVICA® By Your Side Program as a part of all program enrollments. If you would like to have a benefits verification performed on behalf of your patient and receive a copy of the results, please select the check box below and provide the insurance information requested.

Please enter patient’s insurance information

IMPORTANT INFORMATION: By submitting this form you are referring the above patient to PCYC’s patient support program to determine eligibility and receive support related to a PCYC product. Please share this information with your patient. (1) IMBRUVICA® By Your Side is a Pharmacyclics, LLC, (“PCYC”) and Janssen Biotech, Inc. sponsored program that provides personalized patient support (“By Your Side”). (2) PCYC, its affiliates, collaborators and agents (“PCYC”) will use your personal information, including your health information, collected through your enrollment and participation in “By Your Side” to: (1) provide you with support and communications for your prescribed product; and (2) perform research and analytics.

For more information about PCYC’s Privacy Policy practices or how to opt-out, visit https://www.pharmacyclics.com/privacy-policy.

Registration complete!

Thank you for enrolling your patient in IMBRUVICA® By Your Side! Make sure to DOWNLOAD and PRINT or EMAIL the IMBRUVICA® By Your Side patient information to give to your patient before leaving your office.

To Request a Benefit Verification: Call: 1-888-YourSide (1-888-968-7743). Choose option 2 for Healthcare Professional. Then select option 1 to speak to an Access Specialist.

What to expect next:

Remind your patient to expect a call from an Ambassador within one business day (call may come from any area code, including a toll free number).

Ambassadors provide important educational resources, answer questions and help navigate the prescription process and identify ways patients may be able to save on IMBRUVICA®.

IMBRUVICA® Copay Card

Your patient has qualified for the copay card.

RxBIN: 610524 RxGRP: IMB57962 RxPCN: Loyalty ISSUER: 80840 ID: XXXXXXXXXX

*Eligible patients may pay as little as $0 per prescription of IMBRUVICA®. Rules and maximum limits apply. Patients currently using the IMBRUVICA® Copay Card are not eligible for retroactive billing or reimbursement of previous copays. The IMBRUVICA® Copay Card is available to patients with commercial prescription coverage for IMBRUVICA® who meet eligibility criteria. The IMBRUVICA® Copay Card cannot be used by patients receiving prescription reimbursement under any federal, state, or government-funded insurance programs, including Medicare Part D, Medicare Advantage Plan, Medicaid, Medigap, VA, DOD, and TRICARE, or where prohibited by law or the patient’s health insurance provider. The IMBRUVICA® Copay program may be updated or discontinued at any time without notice.

This submission cannot be processed.

 

Unfortunately, there is an error in the information you have provided.

For help submitting your request, please call 1-888-YourSide (1-888-968-7743), Monday-Friday, 8AM-8PM ET.

RxBIN: 610524 RxGRP: IMB57962 RxPCN: Loyalty ISSUER: 80840 ID: XXXXXXXXXX

* Eligible patients may pay as little as $0 per prescription of IMBRUVICA®. Rules and maximum limits apply. Patients currently using the IMBRUVICA® Copay Card are not eligible for retroactive billing or reimbursement of previous copays. The IMBRUVICA® Copay Card is available to patients with commercial prescription coverage for IMBRUVICA® who meet eligibility criteria. The IMBRUVICA® Copay Card cannot be used by patients receiving prescription reimbursement under any federal, state, or government-funded insurance programs, including Medicare Part D, Medicare Advantage Plan, Medicaid, Medigap, VA, DOD, and TRICARE, or where prohibited by law or the patient's health insurance provider. The IMBRUVICA® Copay program may be updated or discontinued at any time without notice.

By using this copay card, the patient understands and agrees to comply with these eligibility requirements and terms of use: 

Eligibility 

  • Covered by commercial or private insurance 
  • Reside in the United States (including Puerto Rico, US Virgin Islands, Guam)   
  • The IMBRUVICA® Copay Card cannot be used by patients receiving prescription reimbursement under any federal, state, or government-funded insurance programs, including Medicare Part D, Medicare Advantage Plan, Medicaid, Medigap, VA, DOD, and TRICARE, or where prohibited by law or the patient's health insurance provider

Terms and Conditions of the IMBRUVICA® Copay Card 

  • Patients currently using the IMBRUVICA® Copay Card are not eligible for retroactive billing or reimbursement of previous copays 
  • The IMBRUVICA® Copay program may be updated or discontinued at any time without notice 
  • This offer is good for eligible patients on IMBRUVICA® who are 18 years of age or older, are residents of the United States, Puerto Rico, US Virgin Islands or Guam, and have a valid prescription for IMBRUVICA® 
  • This program is not available to individuals enrolled in federal or state subsidized healthcare programs that cover prescription drugs, including Medicare, such as Medicare Part D prescription drug benefit, Medicare Advantage, Medicaid, TRICARE, or any other federal or state healthcare plan, including pharmaceutical assistance programs. Participants certify that they will not seek reimbursement or compensation from any of these programs, including a flexible spending account, a Health Savings Account (HSA), or a Health Reimbursement Account (HRA)
  • Individuals who become enrolled in a federal or state subsidized healthcare program that covers prescription drugs at any point after enrolling in the IMBRUVICA® Copay Card program must immediately stop using their IMBRUVICA® Copay Card and call 855-332-6210 to inform RxCrossroads of their change in status. Individuals are no longer eligible for the IMBRUVICA® Copay Card program effective as of the date of their enrollment in the federal or state subsidized healthcare program 
  • This offer may not be combined with any other coupon, discount, prescription savings program card, free triaI or other offer
  • Patients are not required to re-enroll in the program. After the initial enrollment, patients will be automatically re-enrolled for each subsequent year in the program, provided that they continue to meet eligibility criteria for the program
  • Before you activate your membership in this program, it is important that you understand that you will be asked to provide personal information that may include identifiers such as your name, address, phone number, and email address, and information related to your insurance, health, and treatment. This information will be used by Pharmacyclics LLC, the manufacturer of IMBRUVICA®, and companies that work with Pharmacyclics LLC, including vendors and affiliates, to provide benefits to you related to the activation and use of your IMBRUVICA® Copay Card, and for internal business purposes including research and analytics. The information you provide will be shared with our vendors, collaborators, and affiliates and as required by law. For more information about the categories of personal information collected by Pharmacyclics and the purposes for which we use personal information, please visit www.pharmacyclics.com and click on the privacy policy link 
  • The IMBRUVICA® Copay Card will be accepted only at participating pharmacies  
  • The selling, purchasing, trading, or counterfeiting of this program information is prohibited
  • Pharmacyclics LLC reserves the right to rescind, revoke, or amend this offer without notice at any time. Void where prohibited, taxed, or otherwise restricted by law

 

IMPORTANT SAFETY INFORMATION

Warnings and Precautions

Hemorrhage: Fatal bleeding events have occurred in patients who received IMBRUVICA®. Major hemorrhage (≥ Grade 3, serious, or any central nervous system events; e.g., intracranial hemorrhage [including subdural hematoma], gastrointestinal bleeding, hematuria, and post procedural hemorrhage) occurred in 4% of patients, with fatalities occurring in 0.4% of 2,838 patients who received IMBRUVICA® in 27 clinical trials. Bleeding events of any grade including bruising and petechiae occurred in 39%, and excluding bruising and petechiae occurred in 23% of patients who received IMBRUVICA®, respectively.

The mechanism for the bleeding events is not well understood.

Use of either anticoagulant or antiplatelet agents concomitantly with IMBRUVICA® increases the risk of major hemorrhage. Across clinical trials, 3.1% of 2,838 patients who received IMBRUVICA® without antiplatelet or anticoagulant therapy experienced major hemorrhage. The addition of antiplatelet therapy with or without anticoagulant therapy increased this percentage to 4.4%, and the addition of anticoagulant therapy with or without antiplatelet therapy increased this percentage to 6.1%. Consider the risks and benefits of anticoagulant or antiplatelet therapy when co-administered with IMBRUVICA®. Monitor for signs and symptoms of bleeding. 

Consider the benefit-risk of withholding IMBRUVICA® for at least 3 to 7 days pre- and post-surgery depending upon the type of surgery and the risk of bleeding.

Infections: Fatal and non-fatal infections (including bacterial, viral, or fungal) have occurred with IMBRUVICA® therapy. Grade 3 or greater infections occurred in 21% of 1,476 patients who received IMBRUVICA® in clinical trials. Cases of progressive multifocal leukoencephalopathy (PML) and Pneumocystis jirovecii pneumonia (PJP) have occurred in patients treated with IMBRUVICA®. Consider prophylaxis according to standard of care in patients who are at increased risk for opportunistic infections.

Monitor and evaluate patients for fever and infections and treat appropriately.

Cytopenias: In 645 patients with B-cell malignancies who received IMBRUVICA® as a single agent, grade 3 or 4 neutropenia occurred in 23% of patients, grade 3 or 4 thrombocytopenia in 8% and grade 3 or 4 anemia in 3%, based on laboratory measurements.

Monitor complete blood counts monthly.

Cardiac Arrhythmias and Cardiac Failure: Fatal and serious cardiac arrhythmias and cardiac failure have occurred with IMBRUVICA®. Grade 3 or greater ventricular tachyarrhythmias occurred in 0.2% of patients, Grade 3 or greater atrial fibrillation and atrial flutter occurred in 4%, and Grade 3 or greater cardiac failure occurred in 1% of 1,476 patients who received IMBRUVICA® in clinical trials. These events have occurred particularly in patients with cardiac risk factors, hypertension, acute infections, and a previous history of cardiac arrhythmias.

At baseline and then periodically, monitor patients clinically for cardiac arrhythmias and cardiac failure. Obtain an ECG for patients who develop arrhythmic symptoms (e.g., palpitations, lightheadedness, syncope, chest pain) or new onset dyspnea. Manage cardiac arrhythmias and cardiac failure appropriately, and if it persists, consider the risks and benefits of IMBRUVICA® treatment and follow dose modification guidelines.

Hypertension: Hypertension occurred in 19% of 1,476 patients who received IMBRUVICA® in clinical trials. Grade 3 or greater hypertension occurred in 8% of patients. Based on data from 1,124 of these patients, the median time to onset was 5.9 months (range, 0.03 to 24 months).

Monitor blood pressure in patients treated with IMBRUVICA® and initiate or adjust anti-hypertensive medication throughout treatment with IMBRUVICA® as appropriate.

Second Primary Malignancies: Other malignancies (10%), including non-skin carcinomas (4%), occurred among the 1,476 patients who received IMBRUVICA® in clinical trials. The most frequent second primary malignancy was non-melanoma skin cancer (6%).

Tumor Lysis Syndrome: Tumor lysis syndrome has been infrequently reported with IMBRUVICA®. Assess the baseline risk (e.g., high tumor burden) and take appropriate precautions.  

Monitor patients closely and treat as appropriate.

Embryo-Fetal Toxicity: Based on findings in animals, IMBRUVICA® can cause fetal harm when administered to a pregnant woman. Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment with IMBRUVICA® and for 1 month after the last dose. Advise males with female partners of reproductive potential to use effective contraception during the same time period.

ADVERSE REACTIONS

B-cell malignancies: The most common adverse reactions (≥30%) in patients with B-cell malignancies (MCL, CLL/SLL, WM and MZL) were thrombocytopenia (54.5%)*, diarrhea (43.8%), fatigue (39.1%), musculoskeletal pain (38.8%), neutropenia (38.6%)*, rash (35.8%), anemia (35.0%)*, and bruising (32.0%).

The most common Grade ≥ 3 adverse reactions (≥5%) in patients with B-cell malignancies (MCL, CLL/SLL, WM and MZL) were neutropenia (20.7%)*, thrombocytopenia (13.6%)*, pneumonia (8.2%), and hypertension (8.0%).

Approximately 9% (CLL/SLL), 14% (MCL), 14% (WM) and 10% (MZL) of patients had a dose reduction due to adverse reactions. Approximately 4-10% (CLL/SLL), 9% (MCL), and 7% (WM [5%] and MZL [13%]) of patients discontinued due to adverse reactions.

cGVHD: The most common adverse reactions (≥20%) in patients with cGVHD were fatigue (57%), bruising (40%), diarrhea (36%), thrombocytopenia (33%)*, muscle spasms (29%), stomatitis (29%), nausea (26%), hemorrhage (26%), anemia (24%)*, and pneumonia (21%).

The most common Grade 3 or higher adverse reactions (≥5%) reported in patients with cGVHD were pneumonia (14%), fatigue (12%), diarrhea (10%), neutropenia (10%)*, sepsis (10%), hypokalemia (7%), headache (5%), musculoskeletal pain (5%), and pyrexia (5%).

Twenty-four percent of patients receiving IMBRUVICA® in the cGVHD trial discontinued treatment due to adverse reactions. Adverse reactions leading to dose reduction occurred in 26% of patients.

*Treatment-emergent decreases (all grades) were based on laboratory measurements.

DRUG INTERACTIONS

CYP3A Inhibitors: Co-administration of IMBRUVICA® with strong or moderate CYP3A inhibitors may increase ibrutinib plasma concentrations. Increased ibrutinib concentrations may increase the risk of drug-related toxicity. Dose modifications of IMBRUVICA® are recommended when used concomitantly with posaconazole, voriconazole, and moderate CYP3A inhibitors. Avoid concomitant use of other strong CYP3A inhibitors. Interrupt IMBRUVICA® if strong inhibitors are used short-term (e.g., for ≤ 7 days). Avoid grapefruit and Seville oranges during IMBRUVICA® treatment, as these contain strong or moderate inhibitors of CYP3A. See dose modification guidelines in USPI sections 2.3 and 7.1.

CYP3A Inducers: Avoid coadministration with strong CYP3A inducers.

SPECIFIC POPULATIONS

Hepatic Impairment (based on Child-Pugh criteria): Avoid use of IMBRUVICA® in patients with severe hepatic impairment. In patients with mild or moderate impairment, reduce recommended IMBRUVICA® dose and monitor more frequently for adverse reactions of IMBRUVICA®.

Please see full Prescribing Information.

 

INDICATIONS

IMBRUVICA® (ibrutinib) is a kinase inhibitor indicated for the treatment of adult patients with:

  • Mantle cell lymphoma (MCL) who have received at least one prior therapy.
    • This indication is approved under accelerated approval based on overall response rate. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial(s).
  • Chronic lymphocytic leukemia (CLL)/Small lymphocytic lymphoma (SLL).
  • Chronic lymphocytic leukemia (CLL)/Small lymphocytic lymphoma (SLL) with 17p deletion.

  • Waldenström's macroglobulinemia (WM).
  • Marginal zone lymphoma (MZL) who require systemic therapy and have received at least one prior anti-CD20-based therapy.
    • This indication is approved under accelerated approval based on overall response rate. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial(s).
  • Chronic graft versus host disease (cGVHD) after failure of one or more lines of systemic therapy.

IMPORTANT SAFETY INFORMATION

INDICATIONS