Sandoz One Source offers exceptional, user-friendly support for patients taking ZIEXTENZO.
 
 
 
 
The Sandoz One Source Commercial Co-Pay Program for ZIEXTENZO supports eligible,* commercially insured patients with their out-of-pocket co-pay costs for ZIEXTENZO.
 
 
 
  • For eligible,* commercially insured patients
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  • No income requirements
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  • Virtual co-pay card ensures that patients have immediate access to their benefits
 
 
Online co-pay enrollment 
 
 
 
 
 
  • Instruct your patients to enroll in co-pay online
  • Submit an online Sandoz One Source enrollment form
  • Download and fax the Sandoz One Source enrollment form to 1-844-726-3695
 
 
Confirm which benefit your patient will use. The ZIEXTENZO Commercial Co-pay Card may be used for either medical or pharmacy benefits.
 
 
 
  • Enter co-pay card just like an insurance card as additional insurance benefit (eg, secondary, tertiary, etc)
  • Submit claim
  • Receive remittance and payment
 
 
  • Get one-time registration of co-pay card with pharmacy
  • Patient provides co-pay card information to their pharmacy for processing
 
 
 
 
 
Sandoz One Source provides comprehensive support services designed to help simplify and support patient access.
 
  • Benefit investigations
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  • Prior authorization support
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  • Appeals support
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  • Independent foundation information
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  • Patient Assistance Program
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  • Reimbursement support
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Verify payer-specific coding requirements. For reimbursement information, please contact Sandoz One Source.
 
J3590 Unclassified biologics
C9399 Unclassified drugs or biologicals
Injection: clear, colorless to slightly yellowish solution supplied in a single-dose prefilled syringe for manual use containing 6 mg pegfilgrastim, supplied with a 27-gauge, 1/2-inch needle with an UltraSafe Passive™ Needle Guard1 Pack of 1 sterile 6 mg/0.6 mL prefilled syringe 61314-866-01 61314-0866-01
Injection: clear, colorless to slightly yellowish solution supplied in a single-dose prefilled syringe for manual use containing 6 mg pegfilgrastim, supplied with a 27-gauge, 1/2-inch needle with an UltraSafe Passiveā„¢ Needle Guard1 Pack of 1 sterile 6 mg/0.6 mL prefilled syringe
61314-866-01 61314-0866-01
ICD-10-CM Allowable diagnosis codes vary by payer. Report the appropriate diagnosis code(s) to describe the patient's condition. Primary and secondary diagnosis codes may be required
 
 
CPT codes describe the therapeutic injection or infusion.
 
 
96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
 
 
 Download Claims Submission
Operational Guide
 
 
 
 
*
Eligibility Requirements: Maximum benefit of $10,000 annually. Prescription must be for an approved indication. This program is not health insurance. This program is for insured patients only; cash-paying or uninsured patients are not eligible. Patients are not eligible if prescription for ZIEXTENZO is paid, in whole or in part, by any state or federally funded programs, including but not limited to Medicare (including Part D, even in the coverage gap) or Medicaid, Medigap, VA, DOD, or TRICARE, or private indemnity plans that do not cover prescription drugs, or HMO insurance plans that reimburse the patient for the entire cost of their prescription drugs, or where prohibited by law. Co-Pay Program may apply to out-of-pocket expenses that occurred within 120 days prior to the date of the enrollment. Co-Pay Program may not be combined with any other rebate, coupon, or offer. Co-Pay Program has no cash value. Sandoz reserves the right to rescind, revoke, or amend this offer without further notice.
Training via video and telephone are also available.
Additional conditions apply. Product shall be eligible for replacement only (no credit will be issued). Spoilage applies only to infused or injected products. Samples are not eligible for spoilage replacement. Replacement is not available if product has been administered. Sandoz can ship replacement product only to licensed entities. All spoilage replacement requests are subject to review. If already billed or submitted to insurance, or a co-pay or co-insurance payment was received, replacement is not available. Replacement due to loss of refrigeration is limited to five (5) packs per incident, based on SKU dispensing pack quantity, unless the loss was caused by the failure of a Sandoz-provided refrigerator.
 
 
CPT=Current Procedural Terminology; HCPCS=Healthcare Common Procedure Coding System; HHRN=home health registered nurse; NDC=National Drug Code.
 
 
Reference: 1. ZIEXTENZO Prescribing Information. Sandoz Inc. August 2019.