GBT Source Solutions^®—helping your Oxbryta patients start and stay on treatment as prescribed

Enroll your Oxbryta patients in GBT Source Solutions today

How to enroll:

Complete Prescriber pages 1-2 of the GBT Source Enrollment Form, which includes a valid Oxbryta prescription. Have your patient (or their Authorized Caregiver*) complete and sign the Patient Authorization and Consent Form to receive support from GBT Source Solutions.

*An Authorized Caregiver is someone who is legally authorized to make decisions on behalf of the patient.

GBT Source HCP Portal

Streamline patient enrollment: enroll
patient into GBT Source.

Download/print/fax

Download the Prescription/
Enrollment Form

Fax the completed form to
(888) 418-4178

English

Spanish

English

Spanish

Enrollment into GBT Source^TM

HCP completes and sends all necessary enrollment information to GBT Source
Patient completes and signs Authorization Form, and form is sent to GBT Source

GBT Source reviews benefits and coverage requirements

Informs HCP of prior authorization requirements
Informs HCP of appeal requirements, if needed

GBT Source communicates benefit investigation findings to insured patients

Informs patient of out-of-pocket costs and potential support
Informs HCP of discussion with patient and next steps

Fulfillment

GBT Source sends enrollment form (prescription) to specialty pharmacy
Specialty pharmacy contacts patient to schedule shipment

Ongoing refill and adherence services

Specialty pharmacy contacts patient on a regular basis to schedule and send refills
Specialty pharmacy and GBT Source continue ongoing contact with patient to help address access and adherence challenges

Helpful tips to streamline enrollment

Once you’ve talked to your patient about the benefits of enrolling in GBT Source:

Complete all sections of the Prescription/Enrollment Form and sign/enter the date in the appropriate boxes

Verify that patient’s contact and insurance information is correct (you may also include a copy of the front and back of your patient’s insurance card with the Prescription/Enrollment Form)

Provide your contact and alternative office contact details to GBT Source for quick and efficient communication

Make sure your patient (or their Authorized Caregiver) reads, signs, and dates the Patient Authorization and Consent Form

GBT Source Solutions is a resource for your patients that offers access and reimbursement support after Oxbryta has been prescribed

Support for your eligible patients throughout the treatment process

Financial
assistance*

Reimbursement
support^†

Specialty
pharmacy

Adherence
support

Explore the access and support available to your patients

Visit the GBT Source
Solutions website

†Enrolled patients must meet GBT Source eligibility criteria.

Oxbryta has widespread payer coverage nationwide

Patients with commercial health insurance

The GBT Source Commercial Copay Program may cover up to a maximum of $15,000 per calendar year of out-of-pocket expenses related to Oxbryta tablets^‡

Patients who are uninsured

Patients who do not have health insurance may qualify for the GBT Source Solutions Patient Assistance Program (PAP) for Free Drug.^‡ Please call us at (833) 428-4968 for information about this program

Patients with government-funded insurance

For patients with government-funded insurance who need assistance, GBT Source can provide information on independent charitable patient assistance programs. GBT Source does not have any affiliation with these programs nor does GBT determine eligibility

^‡Subject to eligibility and certain terms and conditions.

Our team is here to assist you

For your practice/patients

Access Navigators

Answer questions and provide information on access requirements related to Oxbryta, including GBT Source resources, navigating the insurance process, and the Patient Assistance Program
Assist your practice with on-site, in-person support or with virtual, online support
Contact patients who opted in during enrollment to schedule an introductory session to provide an overview of the services provided by GBT Source

For your patients

Care Coordinators provide reimbursement support

Discuss and verify insurance benefits
Determine if prior authorization is necessary
Inform you and your patients (or their Authorized Caregivers) about out-of-pocket costs
Provide information about appeals process if coverage is denied

A Nurse Support Team provides adherence support^§

Help your patients start and stay on Oxbryta as prescribed
Provide resources and answer questions about treatment with Oxbryta

^§The Nurse Support team is available to support product adherence, and does not replace a patient’s treatment plan. They do not provide medical advice or case management services.

For your patients/practice

Specialty Pharmacy

Coordinates shipment of Oxbryta once prescribed
Follows up with patients (or their Authorized Caregivers) after shipments are delivered
Monitors prescription refills and requests refill authorization as needed
Notifies you and your patients of any treatment challenges or refill issues
Answers any questions your patients may have (pharmacist available by phone 24/7)

To learn more, call

(833) 428-4968

OPTION 1 TO SPEAK WITH A REPRESENTATIVE

(833-GBT-4YOU) M-F, 8am–8pm ET

GBTSource.com

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INDICATIONS AND USAGE

OXBRYTA is indicated for the treatment of sickle cell disease (SCD) in adults and pediatric patients 4 years of age and older.

This indication is approved under accelerated approval based on increase in hemoglobin (Hb). Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trial(s).

GBT Source Solutions®—helping your Oxbryta patients start and stay on treatment as prescribed