Siliq Solutions

Click here for HIPAA Authorization

Pharmacists: For any instructions, questions, or technical support on accessing the SILIQ Solutions™ Instant Savings Program, call or send SMS to 833-613-2333.

lf the pharmacy does not accept your savings program information, you may still be able to receive savings on your out-of-pocket costs. Have your pharmacy call the SILIQ Solutions^™ Instant Savings Program at 855-797-4547 to discuss other payment options.

The SILIQ Solutions^™ Instant Savings Program will cover the cost of your co-pay amount for SILIQ each month, except for the amount you pay based upon your eligibility to participate. You may pay as little as $0 per month if your commercial insurance covers SILIQ; subject to a $15,000 maximum benefit for the calendar year from patient’s first eligible date of program participation.

If your commercial insurance does not cover SILIQ or coverage is delayed or denied, you may pay as little as $50 per month for SILIQ until coverage is approved or up to 24 months from program initiation; subject to process requirements outlined in the Eligibility Criteria and Terms and Conditions.

If a commercially insured patient’s insurance covers SILIQ, he or she may pay as little as $0 per month for SILIQ, up to a maximum savings limit of $15,000 for the calendar year from the patient’s first eligible date of program participation. Patient is responsible for all additional costs and expenses after savings program limit is reached.

Participation in the SILIQ $50 per month program, for eligible patients whose commercial insurance does not cover SILIQ, will expire 24 months from program initiation. During this time, health care providers and patients are encouraged to work together to submit appeals to the patient’s health plan in order to obtain coverage to ensure continued treatment with SILIQ.

These offers are valid for commercially insured patients being treated with SILIQ (brodalumab) injection, for subcutaneous use, for an approved indication, and are good for use only with a SILIQ prescription at the time the prescription is filled.

Uninsured patients are not eligible to participate in the instant savings program.

These offers are not valid for any person eligible for reimbursement of prescriptions, in whole or in part, by any federal, state or other governmental programs, including but not limited to Medicare (including Medicare Advantage and Part A, B and D Plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan, or any other federal or state health care programs.

Eligible patients may not seek reimbursement for all or any part of the benefit received through these offers and are responsible for making any required reports of use of these offers to any insurer or other third party who pays any part of the prescription filled.

These offers are good only in the USA, including Puerto Rico, at pharmacies enrolled in the SILIQ REMS Program. These offers are not valid in states where otherwise prohibited, taxed, or otherwise restricted.

Patient must be 18 years of age or older to redeem these offers for him or herself or for a minor.

This savings program is only good for use with SILIQ. No other purchase necessary.

This savings program is not health insurance.

This savings program membership is not transferable. The selling, purchasing, trading, or counterfeiting of this savings program membership information is prohibited by law. Void if reproduced.

These offers are not valid with other offers. This savings program membership information has no cash value. No cash back.

Ortho Dermatologics’ affiliated entities reserve the right to rescind, revoke, terminate, or amend these offers at any time, without notice.

The patient understands and agrees to comply with the terms and conditions of these offers.

PATIENT AUTHORIZATION By clicking ENROLL NOW for this Patient Authorization Form, I confirm that I authorize my healthcare providers, pharmacies and health plans to disclose my Protected Health Information (“PHI”) related to the Siliq Solutions services such as my demographic information (e.g., name, address, phone number, health insurance), diagnosis, medical condition, treatment and prescription information (e.g., dose, prior medications) to Bausch Health US, LLC and its agents and contractors (“Bausch Health”), and for Bausch Health to receive, use and disclose my PHI, to:

establish my eligibility for benefits through Siliq Solutions;

communicate with my healthcare providers, health plans and me about my medical care as it relates to SILIQ^® (brodalumab) injection, for subcutaneous use;

provide reimbursement and product support services including facilitating the provision of SILIQ to me;

contact me directly by phone, mail, or email, about and enroll me in, Siliq Solutions support services;

investigate, verify, assist with, and coordinate my coverage for SILIQ with my health care providers and health plan;

coordinate prescription fulfillment;

conduct analyses related to the quality, efficacy, and safety of SILIQ, as well as patient access and adherence to SILIQ;

provide my healthcare providers and me with educational materials, information, and services related to SILIQ.

I understand that there is some risk that email communications could be intercepted or accessed by third parties, and consent to Bausch Health communicating with me via email in connection with the Siliq Solutions services. I understand that my PHI will not be used or disclosed by Bausch Health for any other purpose unless permitted by applicable law or unless my personally identifiable information is removed. I understand that once my PHI has been disclosed to Bausch Health, federal privacy laws may no longer restrict its further disclosure. I further understand that I may refuse to sign this Patient Authorization Form. My Healthcare Providers or Insurers will not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits on my signing this Authorization Form. If I do not sign the Patient Authorization Form, or if I revoke this Authorization, I understand that I will not be able to participate in or receive assistance from Siliq Solutions. I understand that my Pharmacy may receive payment or a fee from Bausch Health in exchange for disclosing certain information to Bausch Health pursuant to this Authorization. This Authorization will continue in effect until Bausch Health is no longer providing me with Siliq Solutions services or otherwise as required by state law. I have the right to revoke this Authorization at any time by calling Siliq Solutions at 855-460-7928 or by contacting my healthcare provider(s) or health plans, sending a letter to Siliq Solutions at P.O. Box 220761, Charlotte, NC, 28222 or sending a fax to Siliq Solutions at 888-777-5645. If I revoke this Authorization, I understand that I will no longer be able to participate in the Siliq Solutions program. In addition, the revocation will prohibit further disclosures of my PHI to Bausch Health, but will not affect previous uses or disclosures of my PHI made in reliance on this Authorization. If the support services for SILIQ are discontinued, I understand that this Authorization will also end. My signature below confirms I have read, understand and agree to the Patient Authorization to release my Protected Health Information to Bausch Health US, LLC, its agents and contractors, as described in the Patient Authorization.

If you have any questions or problems, please contact
the SILIQ Solutions^™ Instant Savings Program

855-797-4547

Monday through Friday, 9 AM to 5 PM ET

Important Safety Information

What is the most important information I should know about SILIQ?

Suicidal thoughts and behavior: Some patients taking SILIQ have had suicidal thoughts or ended their own lives. This risk is higher if you have a history of suicidal thoughts or depression. It is not known if SILIQ causes these thoughts and actions. Get medical help right away or call the National Suicide and Crisis Lifeline at 988, if you or a family member notices that you have any of the following symptoms:

new or worsening depression, anxiety, or mood problems
thoughts of suicide, dying, or hurting yourself
attempt to commit suicide, or acting on dangerous impulses
other unusual changes in your behavior or mood

Because of your risk of suicidal thoughts and behavior during your treatment with SILIQ, SILIQ is available only through a restricted distribution program called the SILIQ Risk Evaluation and Mitigation Strategy (REMS). SILIQ can only be prescribed by a healthcare provider certified with the program. Your healthcare provider will give you a SILIQ patient/wallet card about symptoms that need medical attention right away. Carry the card with you during treatment with SILIQ and show it to all of your healthcare providers. SILIQ is only available through pharmacies that participate in the SILIQ REMS. Your healthcare provider can give you information about how to find a participating pharmacy. For more information, go to www.SILIQREMS.com or call 1-855-511-6135.

Serious Allergic Reactions Get medical help right away if you get any of the following signs or symptoms of a serious allergic reaction including swelling of the face, lips, or tongue, trouble breathing or swallowing, itching, dizziness or feel faint, rash, hives, or redness all over your body, chest pain or tightness.

Serious Infections: SILIQ may lower the ability of your immune system to fight infections and may increase your risk of infections:

Your healthcare provider should check you for tuberculosis (TB) before starting treatment with SILIQ and may treat you for TB before starting SILIQ if you have TB or a history of it
You and your healthcare provider need to watch closely for signs and symptoms of infection during treatment with SILIQ, including fever, sweats, chills, shortness of breath, stomach issues, muscle aches, cough, sore throat or trouble swallowing, warm/red/painful skin sores, burning while urinating or more frequent urination than normal

Who should not use SILIQ?

Do not use SILIQ if you are allergic to brodalumab or any of the ingredients in SILIQ or if you have Crohn’s disease. Tell your healthcare provider if you develop diarrhea, bloody stools, stomach pain or cramping, sudden or uncontrollable bowel movements, loss of appetite, constipation, weight loss, fever or tiredness as these may be symptoms of Crohn’s disease.

Before starting SILIQ, tell your healthcare provider if you:

have a history of mental health problems, including suicidal thoughts, depression, anxiety, or mood problems
have an infection that does not go away or keeps coming back
have TB or have been in close contact with someone with TB
have recently received or are scheduled to receive an immunization (vaccine). You should avoid getting live vaccines while being treated with SILIQ
are or plan to become pregnant or are breastfeeding or plan to do so. It is unknown if SILIQ can harm your unborn or newborn baby

Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements.

How should I use SILIQ?

See the detailed “Instructions for Use” that come with your SILIQ for information on the right way to store, prepare, and give your SILIQ injections at home, and how to properly throw away (dispose of) used SILIQ prefilled syringes. Use SILIQ exactly as your healthcare provider tells you to use it.

What are possible side effects of SILIQ?

SILIQ may cause serious side effects including severe skin reactions that look like eczema. These reactions can happen during treatment with SILIQ from days to months after your first dose and can sometimes lead to hospitalization. Your healthcare provider may temporarily stop treatment with SILIQ if you develop severe skin reactions. Tell your healthcare provider if you have any of the following signs or symptoms: redness or rash; itching; small bumps or patches; your skin is dry or feels like leather; blisters on the hands or feet that ooze or become crusty or skin peeling.

See “What is the most important information I should know about SILIQ?” and “Who should not take SILIQ?”

The most common side effects of SILIQ include: joint pain, headache, tiredness, diarrhea, mouth or throat pain, nausea, muscle pain, injection site reactions, flu, low white blood count (neutropenia), and fungal infections of the skin. Call your doctor for medical advice on side effects. You are encouraged to report negative side effects of prescription drugs to Bausch Health at 1-800-321-4576 or FDA at 1-800-FDA-1088 or visit www.fda.gov/medwatch.

What is SILIQ?

SILIQ^® injection is a prescription medicine used to treat adults with moderate to severe plaque psoriasis:

who may benefit from injections or pills (systemic therapy) or phototherapy (treatment using ultraviolet light treatment) and
who have tried another systemic therapy that didn’t work or stopped working

It is not known if SILIQ is safe and effective in children.

Click here for full Prescribing Information, including Boxed Warning about suicidal ideation and behavior, and Medication Guide.

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What is SILIQ?

What is the most important information I should know about SILIQ?

Suicidal thoughts and behavior:

Some patients taking SILIQ have had suicidal thoughts or ended their own lives. This risk is higher if you have a history of suicidal thoughts or depression. It is not known if SILIQ causes these thoughts or actions. Get medical help right away if you or a family member notices that you have any of the following symptoms

SILIQ^® injection is a prescription medicine used to treat adults with moderate to severe plaque psoriasis:

who may benefit from injections or pills (systemic therapy) or phototherapy (treatment using ultraviolet light treatment) and

What is the most important information I should know about SILIQ?

Suicidal thoughts and behavior: