SPRYCEL® (dasatinib) Patient Assistance
1. How does the program work?
- The Destination Access SPRYCEL Patient Assistance Program provides free SPRYCEL to qualified patients who are prescribed SPRYCEL
- Eligible patients will have an annual household adjusted gross income of $75,000 or less. Destination Access reviews all applications on a case-by-case basis and may consider additional factors when evaluating a patient’s level of financial hardship, such as out-of-pocket expenses related to the patient’s current disease state. Please contact Destination Access for more information
- Annual enrollment is required. For a patient to be enrolled in the program, treatment must be ongoing and provided on an outpatient basis
- Patients who are uninsured, who are insured and have been denied coverage for SPRYCEL, or who have reached an annual or a lifetime insurance benefit maximum may be eligible to receive free SPRYCEL through the program
- At the discretion of the patient’s healthcare provider, patients may elect to have their SPRYCEL shipped directly to their residence, as opposed to their healthcare provider’s office
- Patients who have been receiving their SPRYCEL through the program for 6 months or less are eligible to refill their SPRYCEL every 30 days. The patient’s healthcare provider may request a refill by faxing the completed refill form to Destination Access on a monthly basis, in 21 days or less from the time of the patient’s last shipment of SPRYCEL
- Patients whose initial date of enrollment into the program exceeds 6 months may be eligible to receive 60-day-supply refills at the discretion of their physician. Please contact Destination Access to learn more
- Refill forms may be obtained by clicking on the link below. In addition, the information can be typed directly into the form, saved to the desktop, printed, signed by the prescriber, and faxed to Destination Access for processing. Healthcare providers will also be faxed a refill form 14 days following each shipment of SPRYCEL
2. How does a patient apply for the Destination Access SPRYCEL Patient Assistance Program?
- The patient and healthcare provider will need to complete the enrollment form provided in the link below and obtain any other documentation that is required. The information can be typed directly into the downloaded enrollment form, saved to the desktop, printed, and signed by the prescriber and the patient. Fully completed applications should be faxed to Destination Access for processing. Alternatively, the patient’s healthcare provider may call Destination Access to provide certain information requested on the enrollment form over the phone; the specialist will enter the information into the enrollment form prior to faxing it to the practice
- SPRYCEL Enrollment Form
- To help expedite the completion of the enrollment form, a Patient Enrollment Form Checklist is now available to assist patients in gathering the information that they will need to complete the patient portion of enrollment form
- You can obtain the Patient Enrollment Form Checklist by clicking on the link below or by calling Destination Access to have one faxed or e-mailed to you
Patient Enrollment Form Checklist
- A Destination Access program specialist will contact the patient’s healthcare provider on or before the next business day to discuss any of the alternative sources of funding or coverage that may be available to the patient, including whether the patient qualifies to receive free SPRYCEL through the Destination Access SPRYCEL Patient Assistance Program
- If the patient would like to be considered for participation in the Destination Access SPRYCEL Patient Assistance Program, please include a photocopy of the patient’s proof of annual household income with the enrollment form. Examples of proof of income include the applicant’s most recent federal tax return and social security or retirement income statements. Other documentation for proof of income may be considered. Please call Destination Access for more detailed information about what other forms of proof of income documentation are acceptable.
- Please fax the completed application with the required signatures, along with proof of income documentation, to Destination Access at 1-888-776-2370
If the patient meets the eligibility criteria for the SPRYCEL Patient Assistance Program, a Destination Access program specialist will contact the patient’s healthcare provider no later than the next business day to initiate a product shipment.
3. What are the eligibility criteria for the SPRYCEL Patient Assistance Program?
- The patient must be a U.S. citizen or a U.S. legal resident
- The patient must have an annual household adjusted gross income of $75,000 or less. Destination Access reviews all applications on a case-by-case basis and may consider additional factors when evaluating a patient’s level of financial hardship, such as out-of-pocket expenses related to the patient’s current disease state. Please contact Destination Access for more information
- Patients who have exceeded either an annual or lifetime maximum benefit on their insurance coverage for SPRYCEL may be considered eligible for patient assistance
- Uninsured and insured patients who are denied coverage for SPRYCEL by their insurer may be eligible to receive free SPRYCEL through the Program
- Treatment must be ongoing in order to receive free product through the Patient Assistance Program. Please note that Destination ACCESS does not provide product replacement as part of its Patient Assistance Program
- The patient must be treated with SPRYCEL on an outpatient basis in order to qualify for the Program
- Incarcerated patients are not eligible to receive SPRYCEL through the Patient Assistance Program
4. Is it possible for patients who have exhausted their health plan’s lifetime or annual maximum benefit amount to be considered eligible to receive free product through the SPRYCEL Patient Assistance Program?
Yes, patients who have exceeded their health plan�s annual or lifetime maximum benefit amount are considered to be uninsured under the Program guidelines; therefore, if they meet all of the other program eligibility criteria, they may qualify to receive free SPRYCEL through the SPRYCEL Patient Assistance Program.
5. Are patients who are enrolled in a Medicare Part D Plan eligible to receive free SPRYCEL through the Program?
Generally, patients receiving benefits under a Medicare Part D plan are not eligible for assistance through the Destination Access SPRYCEL Patient Assistance Program. However, during 2009, Medicare Part D enrollees may apply for assistance through a case-by-case appeals process based on significant financial and medical need. Additionally, new applicants cannot qualify for the program if they are eligible for and receiving the Medicare Part D Low Income Subsidy (LIS).
Did you know you may be eligible to have your medication shipped directly to your home? Learn more about our Direct-to-Patient Shipment Program to see if you qualify.
SPRYCEL® (dasatinib)
Indications and Important Safety Information for Patients
Indications and Usage
SPRYCEL® (dasatinib) is a prescription medicine used to treat adults who have:
- chronic myeloid leukemia (CML) who are no longer benefitting from, or cannot tolerate, prior treatment including GLEEVEC® (imatinib mesylate)
- Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) who are no longer benefitting from, or cannot tolerate, prior treatment
Important Safety Information about SPRYCEL
- SPRYCEL is currently not recommended for patients who have not previously had a trial of GLEEVEC® (imatinib mesylate)
- Women who are pregnant or planning to become pregnant should not take SPRYCEL
- are pregnant or planning to become pregnant. SPRYCEL may harm an unborn baby. Women should avoid becoming pregnant while undergoing treatment with SPRYCEL. Tell your healthcare provider immediately if you become pregnant or plan to become pregnant while taking SPRYCEL
- are breast-feeding. It is not known if SPRYCEL can pass into your breast milk or if it can harm your baby. Do not breast feed if you are taking SPRYCEL
- are a sexually active male. Men who take SPRYCEL are advised to use a condom to avoid pregnancy in their partner
- have a liver or heart problem
- are lactose intolerant
SPRYCEL is eliminated from your body through the liver. The use of certain other medicines may alter the levels of SPRYCEL in your bloodstream. Likewise, levels of other medicines in your bloodstream can be affected by SPRYCEL. Such changes can increase the side effects, or reduce the activity of the medicines you are taking, including SPRYCEL.
- Medicines that increase the amount of SPRYCEL in your bloodstream are
NIZORAL® (ketoconazole), SPORANOX® (itraconazole), NORVIR® (ritonavir), REYATAZ® (atazanavir sulfate), CRIXIVAN® (indinavir), VIRACEPT® (nelfinavir), INVIRASE® (saquinavir), KETEK® (telithromycin), E-MYCIN® (erythromycin), and BIAXIN® (clarithromycin)
- Medicines that decrease the amount of SPRYCEL in your bloodstream are DECADRON® (dexamethasone), DILANTIN® (phenytoin), TEGRETOL® (carbamazepine), RIMACTANE® (rifampin), and LUMINAL® (phenobarbital)
- Medicines whose blood levels might be altered by SPRYCEL are SANDIMMUNE® (cyclosporine), ALFENTA® (alfentanil), FENTANYL® (fentanyl), ORAP® (pimozide), RAPAMUNE® (sirolimus), PROGRAF® (tacrolimus), and ERGOMAR® (ergotamine)
SPRYCEL is best absorbed from your stomach into your bloodstream in the presence of stomach acid. You should avoid taking medicines that reduce stomach acid such as TAGAMET® (cimetidine), PEPCID® (famotidine), ZANTAC® (ranitidine), PRILOSEC® (omeprazole), PROTONIX® (pantoprazole sodium), NEXIUM® (esomeprazole), ACIPHEX® (rabeprazole), or PREVACID® (lansoprazole) while taking SPRYCEL. Medicines that neutralize stomach acid, such as MAALOX® (aluminum hydroxide/magnesium hydroxide), TUMS® (calcium carbonate), or ROLAIDS® (calcium carbonate and magnesia) may be taken up to 2 hours before or 2 hours after SPRYCEL.
Since SPRYCEL therapy may cause bleeding, tell your healthcare provider if you are using blood thinners, such as COUMADIN® (warfarin sodium) or aspirin.
- Take SPRYCEL with or without a meal. Try to take SPRYCEL at the same time each day
- Swallow SPRYCEL tablets whole with water. Do not break, cut, or crush the tablets
- Do not drink grapefruit juice while taking SPRYCEL
The following information describes the most important side effects of SPRYCEL. It is not a comprehensive list of all side effects recorded in clinical trials with SPRYCEL.
- Low Blood Counts: SPRYCEL may cause low red blood cell counts (anemia), low white blood cell counts (neutropenia), and low platelet counts (thrombocytopenia). Your healthcare provider will check your blood counts regularly during treatment with SPRYCEL and may adjust your dose of SPRYCEL or withhold the drug temporarily in the event your blood counts drop too low. Notify your healthcare provider immediately if you develop a fever while taking SPRYCEL.
- Bleeding: SPRYCEL may cause bleeding. The most serious bleeding events observed in clinical studies included bleeding into the brain leading to death in 1% of patients, and bleeding from the gastrointestinal tract. Less severe events included bleeding from the nose, the gums, bruising of the skin, and excessive menstrual bleeding. Tell your healthcare provider immediately if you have any bleeding or bruising while taking SPRYCEL.
- Fluid Retention: SPRYCEL may cause fluid to accumulate in your legs and around your eyes. In more severe cases, fluid may accumulate in the lining of your lungs, the sac around your heart, or your abdominal cavity. Notify your healthcare provider immediately if you experience swelling, weight gain, or increasing shortness of breath while taking SPRYCEL.
- QT Prolongation: Talk to your healthcare provider if you have QT prolongation, a condition called congenital long QT syndrome, or if you have a family history of QT prolongation. You should also tell your healthcare provider if you are taking a heart rhythm drug or chemotherapy, or are being treated for low levels of potassium or magnesium in your blood before taking SPRYCEL.
Other common side effects of SPRYCEL therapy include diarrhea, headache, shortness of breath, skin rash, fatigue, and nausea. Tell your healthcare provider if you have any side effects.
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