b'Specialty Pharmacy ConsentBIOPLUS SPECIALTY PHARMACY PATIENT GUIDEBOOK1.This acknowledges that my physician has prescribed medication(s) for me and that BioPlus Specialty Pharmacy Services, LLC, a Carelon company and their network of pharmacies including MedScripts Medical Pharmacy, River Medical Pharmacy, Route 300 Pharmacy, and Santa Barbara Specialty Pharmacy (each Pharmacy) will serve as the specialty pharmacy. The route of administration of this medication is indicated on the medication prescription label along with directions for use. I have voluntarily chosen to receive the medication and am of legal age and authorized to execute this consent form. 2.I understand that I have other pharmacy options available and that I have the right to choose my pharmacy provider. Certain programs and health plans may restrict access to in-network providers, pursuant to applicable Federal and state law, and benefit program requirements. I acknowledge that my therapy is under the control of my physician; I select and authorize Pharmacy to furnish the medications and supplies deemed necessary to administer my therapy as ordered by my physician.3.My physician has explained my therapy and treatment to me, alternate therapies available, and the substantial risks and hazards inherent with this therapy. I understand that there may be special instructions or training. I agree to read the instructions and complete any training necessary. I agree to abide by the instructions and training provided and will im-mediately alert the pharmacist and the prescribing physician of any medical conditions which may adversely impact my personal health or the effectiveness of the medication. I further understand that I have the opportunity to ask questions about the medication and all of my questions have been answered.4.I understand all aspects of my home self-care and understand that I have the right to ask any questions and receive answers during my participation in the program. I have been instructed to call 911 for emergency medical attention.5.I have received information regarding biomedical waste disposal, emergency preparedness, and drug information.6.I have received a copy of the Patients Rights and Responsibilities and a copy of the Notice of Privacy Practices, and I understand these documents. I further know that any time I have questions, I can call the pharmacy at the number listed on the prescription label.7.Because I am receiving specialty medications, the pharmacy is required by contract to obtain proof of delivery. I un-derstand that I will be asked to sign for my delivery via the delivery carrier. If I am unable to sign for the delivery, I will sign and return the packing ticket enclosed with my shipment.8.I authorize the pharmacy to bill my insurance provider. I understand that if no insurance coverage exists or if an insurer fails to pay, I may be financially responsible for the incurred charges.9.Various drug manufacturers and other entities offer patient assistance programs that provide payment assistance, in-cluding without limitation co-pay cards, or cost reductions for certain therapies, prescriptions, and medications. As ap-plicable, I authorize the pharmacy to take all necessary actions to enroll and register me in patient assistance programs for which I am qualified for the purposes of identifying and obtaining such payment support.10.If I have insurance coverage provided through any type of state-, Federal-, or government-funded programs, (Medicare, Medicaid, Federal Employees Health Benefits, TRICARE, VA), I am not eligible to participate in the co-pay Program. I attest that my insurance plan is not a state or Federal government insurance plan, such as Medicare, Medicaid, or Tricare. 27'