Matt Neal

421 SE County Rd
Ada, OK 74820
Congratulations!

You’ve been approved for funding from The LLS Co-Pay Assistance Program.

This welcome packet includes all the information you need to get started with the co-pay program. Here’s what you’ll find:

• An Award Letter that gives you:

o Basic information about your funding and submitting claims
o Your temporary LLS Pharmacy Benefit Card. You can use this card at your pharmacy to pay for prescriptions
related to your blood cancer treatment. Pay with the card, and you don’t have to submit a separate
claim for prescription medicine.

• A Copy of Terms and Conditions and Patient Attestation. This form is for your records only. It explains:
o How LLS uses a patient’s personal and medical information
o The patient’s rights as a participant in the co-pay program.
o The attestations you (or someone on your behalf) made as part of the application process.

• Covered and Not Covered Expenses. This sheet tells you what expenses are covered by the co-pay program.

• How to Submit a Claim. These step-by-step instructions help you submit a claim for payment.It also provides
checklists to help you gather documents you need to support your claim.

• Proof of Expenditure (POE) Form. Submit a copy of this form with every claim.

Questions? Contact us:

• Phone: (877) 557-2672, Monday through Friday, 8:30 a.m. to 5:00 p.m. ET
• Email: financialassistance@lls.org
• Fax: (877) 267-2932
• Mail: The Leukemia & Lymphoma Society
Co-Pay Assistance Program
P.O. Box 12268
Newport News, VA 23612

We hope the support from the co-pay program helps you focus on treatment and getting well. Our goal is your improved
health.

Co-Pay Assistance Program

P.O. Box 12268
Newport News, VA 23612
877-557-2672 or 877-LLS-COPAY
Fax: (877) 267-2932 or 877-COPAY-FAX
01/18/2023

Dear Matt Neal:

Congratulations! You have been approved for funding from The Leukemia & Lymphoma Society’s Co-Pay Assistance Program. You
can use this money right now to help pay for out-of-pocket expenses related to your blood cancer treatment.

This letter gives you basic information about your award. It also includes your temporary LLS Pharmacy Benefit Card. You will receive
your physical Pharmacy Benefit Card in the mail. If you have questions, call us at (877) 557-2672 or send an email to
financialassistance@lls.org.

Fund information
Fund name: Lymphoma
Amount of funding: $5,000.00
Start date: 01/18/2023

End date: 01/18/2024

You may be able to submit claims for treatment-related expenses you had 90 days before your start date. We don’t pay for any
treatment or services you received before your diagnosis date.

Confirming your diagnosis

Your doctor MUST submit confirmation of diagnosis to LLS within 30 days of your approval date to keep your award active.
The Diagnosis Verification Form can be downloaded from the online portal, if a portal account was created. You can also call the
program at 877-557-2672, to have another copy sent to you or your physician.

The Diagnosis Verification Form must be received by 02/17/2023.

If your doctor does not submit the form by this date, your account will be closed and you will lose the balance of your award.

Submitting claims
You can start submitting claims right away:
• You can submit as many claims as you have until you use all the money.
• To keep your funding active, you must submit a claim at least every 90 days (3 months). We will send reminders to
help you remember to submit your claims.

If you go 90 days without submitting a claim:

• Your account will be closed and you will lose any remaining money.

You can submit a claim:

• In the online portal: https://cprportal.lls.org/#/login
• By fax: (877) 267-2932
• By mail: The LLS Co-Pay Assistance Program
P.O. Box 12268
Newport News, VA 23612

Co-Pay Assistance Program

P.O. Box 12268
Newport News, VA 23612
877-557-2672 or 877-LLS-COPAY
Fax: (877) 267-2932 or 877-COPAY-FAX
For detailed instructions on how to submit a claim, see the How to Submit a Claim information sheet.

LLS Pharmacy Benefit Card

The LLS Pharmacy Benefit Card is as good as money at your pharmacy! It pays your pharmacy directly for prescriptions related to
your treatment that are covered by the program. When you give the card information to your pharmacist, your cost is instantly
covered.

See your temporary Pharmacy Benefit Card below. You will receive your physical Pharmacy Benefit Card in the mail. You also can
find and print a copy of your card on the online portal.

Patient: Matt Neal

Fund: Lymphoma

Award Period: 10/20/2022 to 01/18/2024

Cardholder: 2000344347

BIN: 610020 PCN: PXXPDMI Group: 99993818

For pharmacy inquiries contact PDMI at 855-701-0227.

For patient inquiries contact LLS at 877-557-2672.

Questions? Contact us:

• Phone: (877) 557-2672, Monday through Friday, 8:30 a.m. to 5:00 p.m. ET
• Email: financialassistance@lls.org
• Fax: (877) 267-2932
• Mail: The Leukemia & Lymphoma Society
Co-Pay Assistance Program
P.O. Box 12268
Newport News, VA 23612

We’re happy to have you part of The LLS Co-Pay Assistance Program. We hope the money you receive helps you focus on
treatment and getting well. Your improved health is our main goal.

Sincerely,
The LLS Co-Pay Assistance Program

Co-Pay Assistance Program

P.O. Box 12268
Newport News, VA 23612
877-557-2672 or 877-LLS-COPAY
Fax: (877) 267-2932 or 877-COPAY-FAX
 Patient Name: Matt Neal Date Application Completed: 01/18/2023

TERMS & CONDITIONS

All information obtained during this screening is true and complete in all respects. Patient will promptly notify LLS if any information
provided is inaccurate or changes, including patient demographics, income level, insurance status, or medical condition. LLS is not liable
for any damages resulting from the accuracy or inaccuracy of any patient information provided to LLS by you or someone on your behalf
(for example, a patient representative, provider, or pharmacy).

Fraud
The prevention of fraud is of utmost importance to LLS. LLS has the right to verify the accuracy of information provided during screening,
all information contained in any claim, and patient’s ongoing program eligibility. Detection of fraud or abuse will result in termination of
the award, the pharmacy card will be deactivated, claims submitted will not be paid, and the applicant will not be eligible to receive
assistance from the LLS Co-Pay Assistance program in the future.

Income Verification
LLS will verify patient’s income through a third-party income verification service. Patient authorizes the use of their social security
number to access credit information to confirm the reported income and ensure it meets eligibility requirements. If the income
information cannot be verified or the information provided during screening is significantly different than the income the third-party
service discovers and reports, LLS will require full income documentation for review.

Patient’s Right to Choose

Patient understands that they have the right to choose and/or change their physician, pharmacy, provider, supplier, therapy, treatment or
medication, without affecting their eligibility or participation in the program. LLS will not be liable for any damages of any kind, without
limitation to the success or failure of medication(s), or for any harm that it may cause.

Release of Information
LLS, its employees and agents are authorized to obtain and discuss medical, treatment, therapy, financial and other information relating
to patient with their health care providers and their staff, pharmacy, employer, insurance company, and any other person or entity
working on the patient’s behalf to confirm eligibility. Neither LLS nor any of its employees or agents will disclose any patient individually
identifiable information to any third party except as provided above, as required by law, as deemed appropriate by LLS to resolve any
potential fraud or audit irregularity, or as necessary or appropriate for LLS to provide assistance to patient under the program. LLS may
use information and data relative to patient to develop aggregate reports as LLS deems appropriate.

Claim Submittal
Patient understands that they must make claims at least once every 90 days following their approval date and that reminder letters will
be sent quarterly. If LLS does not receive a claim within any 90 day period, the award will be closed, the patient will forfeit any remaining
award dollars, and the patient will not be eligible to reapply for assistance until the end of their coverage period. Patient authorizes
payment directly to the hospital, physician, pharmacy or other supplier herein named for the funds available through LLS. Patient is
financially responsible for charges not covered by this program.

LLS will only pay claims that cover dates of service falling within the award coverage period. Patient understands that prescription
insurance coverage is required for program eligibility and that LLS is not responsible for maintaining the continuation of the patient’s
insurance coverage

LLS Co-pay Assistance program continuation is dependent on the availability of funds and the program can be modified or discontinued
at any time if funding is limited or no longer available.

Do you have any questions in relation to the terms and conditions of the program? No
PATIENT ATTESTATION

(The applicant’s attestation and responses will be recorded and kept on file )

Do you the caller/applicant understand and agree to the following, please respond with Yes or No

Do you confirm that you are the patient, or a representative of the patient authorized to attest to and release
the medical and financial information provided in this application? Yes

Do you attest that the information provided is true and complete?Yes

Do you acknowledge that you understand and agree with the terms and conditions reviewed? Yes

Do you understand that the patient has the right and complete freedom to choose and/or change their
physician, pharmacy, provider, therapy, treatment, medication, insurer, without affecting their eligibility or
participation in the program? Yes

Do you authorize [the agent] to electronically sign the patient attestation section of the application on
behalf of the patient?

PATIENT SERVICES OPT-IN

I and my caregiver/family member authorized to speak on my behalf (if specified) would like to be
contacted regarding patient support services Yes

APPLICATION SIGNATURE
Jenny Stull 01/18/2023

Relationship to Patient: Advocate

 The LLS Co-Pay Assistance Program:
How to Submit a Claim

Use these steps to help you submit a claim for payment.

Step 1: Check the Covered and Non-Covered Expense List.

This list is included in your approval packet. You also can find it at www.LLS.org/copay.Before you submit a claim, make sure
the expense is covered by the co-pay program. If you have questions about what’s covered, call (877) 557-2672.

Step 2. Make sure the claim is paid to the same person, provider or company.
Make sure all the expenses on a claim are paid to the same payee—you, a provider, a pharmacy or an insurance company. If
you have more than one payee, submit the expenses on separate claims.

Step 3. Fill out a Proof of Expenditure (POE) form.

This form is included in your approval packet. Fill it out and send it with each claim you submit. If you lose the form, you
can use the online portal and print a form there. If you can’t access the portal, call (877) 557-2672. You can sign up on the
portal at: https://cprportal.lls.org/#/login

Step 4: Gather supporting documents.

See the checklists below to find out what receipts and other paperwork you need for your claim.

Step 5: Submit the POE and supporting documents

• By fax: (877) 267-2932

• In the online portal: https://cprportal.lls.org/#/login
• By mail:
The LLS Co-Pay Assistance Program
P.O. Box 12268
Newport News, VA 23612
• If the payment is to your health insurance company: Fax your claim to (914) 872-6232 at least 15 days before the
payment is due. This fax number is for payments to insurance companies only.

Co-Pay Assistance Program

P.O. Box 12268
Newport News, VA 23612
877-557-2672 or 877-LLS-COPAY
Fax: (877) 267-2932 or 877-COPAY-FAX
Use these checklists to know what documents to submit with your claim.

Checklist 1. To get reimbursed (paid back) for something you’ve already paid for
You can get paid back for payments you’ve already made for treatment, medicine
or health insurance. To get paid back, submit these documents:
A completed POE form
Proof that you’ve made the payment. This may be a receipt, cancelled check, bank statement, or credit card
statement.
A copy of the bill that includes the exact treatment, medicine, or service.
The bill needs to include billing codes and details on the treatments that you received.
A copy of the Explanation of Benefits (EOBs) from your health insurance company. Call the number on your
insurance card to find out how to get this.

If you paid for a prescription and didn’t use your LLS Pharmacy Benefit Card, submit:
A completed POE form
A copy of your prescription history statement/printout. You can get this from the pharmacy. It should have:
• The name of the medicine
• The date you paid for and received the medicine
• What you paid for the medicine
Proof of payment, like a receipt, cancelled check, bank statement, or credit card statement.

Checklist 2. To pay a healthcare provider or a treatment setting, like a hospital or clinic, for treatment or services
Submit these documents:
A completed POE form
A copy of the bill that includes the exact treatment or service. The bill needs to include billing codes and details on
the treatments that you received.
A copy of the Explanation of Benefits (EOBs) from your health insurance company. Call the number on your
insurance card to find out how to get this.

If you paid a provider or treatment setting and need to get paid back, see Checklist 1 to see how to get reimbursed.

Co-Pay Assistance Program

P.O. Box 12268
Newport News, VA 23612
877-557-2672 or 877-LLS-COPAY
Fax: (877) 267-2932 or 877-COPAY-FAX
Checklist 3. To pay for prescription medicine with your LLS Pharmacy Benefit Card
Use your pharmacy benefit card to pay for prescription medicine at your pharmacy with no out-of-pocket cost to you. You
can:
• Use the temporary card printed at the end of your approval letter.
• Use the physical copy of the card you receive in the mail.
• Print a copy of the card in the online portal at:
https://cprportal.lls.org/#/login

If you paid for prescription medicine and didn’t use your pharmacy card, see Checklist 1 to see how to get reimbursed.

Checklist 4. To pay your health insurance company

Fax your claim to (914) 872-6232 at least 15 days before the payment is due. This fax number is for payments to
insurance companies only. If you paid your insurance company and need to get paid back, see Checklist 1 to see how to
get reimbursed.

IMPORTANT: LLS reviews all co-pay claims in the order we receive them. To ensure that your health insurance bills
are paid on time, submit these claims to LLS at least 15 days before the payment is due. This helps prevent dropped
coverage due to late payments. LLS is not responsible for continuing a patient’s health insurance if coverage is dropped
because of a late payment.

Health Insurance: Important Information

Find the insurance you have below to see what documents to submit with your claim for either reimbursement or
payment to your insurance company.

Your insurance What to submit

A completed POE form

A rate sheet that shows the amount you pay for health
If you have health
insurance. You can get this from your employer’s human
insurance through an
resources department or your COBRA administrator. If you’re on
employer or COBRA
a family plan, send the individual and family
rates. The rate sheet also may be called an election letter.
A paystub that shows the amount of money you pay for health
insurance.

Co-Pay Assistance Program

P.O. Box 12268
Newport News, VA 23612
877-557-2672 or 877-LLS-COPAY
Fax: (877) 267-2932 or 877-COPAY-FAX
 Your insurance What to submit

○ If the pay stub has a year-to-date amount (the amount you’ve

paid so far this year): Send your most recent paystub.
○ If the paystub shows just the amount paid from that check and
you don’t have other paystubs: Ask the human resources
department to give you a written letter that includes the amount you’ve
paid for health insurance since your co-pay application was approved.

A completed POE form

If you have health insurance not
A copy of the bill that shows the amount you owe for health
through an employer
insurance and the number of people covered on your plan
A copy of your insurance card
A letter from the insurance company that includes the amount you
pay for health and prescription coverage and the number of people on
your plan. Do not include dental and vision insurance.

A completed POE form

If you have a Medicare A copy of your current Medicare bill or payment coupon that
Supplement plan shows the amount you owe
A copy of your Medicare and/or Medicare Supplement card

A completed POE form

If you have Medicare Part B and/ A copy of your current Medicare bill or payment coupon that
or Part D deductions (taken out of shows the amount you owe
your Social Security or Social A copy of your insurance card
Security Disability check) A statement from the insurance company that includes the amount
you pay for individual health and prescription coverage. Do not
include dental and vision insurance.

LLS Processes claims on a first come, first served basis regardless of how we receive them (by fax or mail or in
the portal).

Questions?
Call us at: (877) 557-2672

Co-Pay Assistance Program

P.O. Box 12268
Newport News, VA 23612
877-557-2672 or 877-LLS-COPAY
Fax: (877) 267-2932 or 877-COPAY-FAX
 The LLS Co-Pay Assistance Program:
Covered Prescription Categories

The LLS co-pay program covers all prescription products including chemotherapy (oral and intravenous) and medicine that are:
• Prescribed by a patient’s health care provider to treat blood cancer
• Covered by the patient’s primary (main) health insurance.

This list includes drug categories often prescribed by health care providers as part of blood cancer treatment. Drugs in these categories are
covered by the co-pay program:
• Anti-anxiety
• Antibiotics
• Anti-fungal
• Anti-nausea
• Anti-seizure
• Antiviral
• Appetite stimulants
• Blood thinners, including anticoagulants
• Chemotherapy- oral and intravenous
• Muscle relaxers
• Pain medicine
• Psychostimulants
• Sleep aids
• Steroids

What if your drug category isn’t in the list?

If your health care provider has prescribed medicine for you related to your treatment that is not in a category listed above, send us a letter
from your provider that includes:
• The name of the drug and dosage
• An explanation as to how the medicine is medically necessary for your treatment. If you don’t submit this information, we cannot approve
your claim.

Contact us at (877) 557-2672 if:

• You’re not sure if your prescription is part of an approved drug category.
• Your claim for a prescription was denied and you think it should be approved.
• You have any questions about the co-pay program.

The co-pay phone lines are open Monday to Friday from 8:30 a.m. to 5:00 p.m. Eastern Time.

The patient has the right to choose or change at any time their healthcare providers; pharmacies or suppliers; health or prescription insurance;
and therapy, treatment and medication. A choice or change does not affect a patient’s participation in the program.

But the patient must have health insurance to participate in the program.

Please be sure to check out the list of Covered and Not Covered Expenses for more information.
It is included in this packet and can be found at www.LLS.org/copay.

Co-Pay Assistance Program

P.O. Box 12268
Newport News, VA 23612
877-557-2672 or 877-LLS-COPAY
Fax: (877) 267-2932 or 877-COPAY-FAX
 The LLS Co-Pay Assistance Program:
Covered and Not Covered Expenses

What’s Covered

• Blood cell boosters and erythropoietin-stimulating agents

• Blood transfusions
• Chemotherapy, including oral and intravenous treatment
• Colonoscopy and endoscopy
• Insurance premiums, co-pays, deductibles and co-insurance for private or government health insurance plans; and
Medicaid spend-down
• Intravenous preparation and maintenance procedures
• Iron chelation therapy
• Kyphoplasty
• Lab services, including blood work, biopsies, cultures, blood draws and bone marrow aspirations, and tissue typing and
stem cell harvesting for transplants
• Photopheresis and ultraviolet (UV) light therapy
• Prescription drugs related to the covered diagnosis or used with blood and marrow stem cell transplants
• Radiation and radioimmunotherapy (RIT)
• Scans and tests, including electrocardiograms (ECGs or EKGs); PET, CT, and MRI scans;ultrasounds; X-rays

What’s Not Covered (includes but is not limited to):

• Dental and vision exams and treatment

• Fertility and reproductive procedures
• Long-term care insurance and cancer insurance
• Hospital stays
• Office visits with no treatment for blood cancer, or for consultations or second opinions
• Over-the-counter (OTC) medicine and vitamins
• Prescribed devices, such as glasses and contacts; pumps, kits and supplies; wheelchairs
• Surgery for diagnosis or that’s not related to blood cancer treatment
• Travel expenses, including air fare, train fare, taxi, hotel, meals, parking and tolls

Please be sure to check out the list of Covered Drug Categories for more information. It is included in this packet and
can be found at www.LLS.org/copay.

Co-Pay Assistance Program

P.O. Box 12268
Newport News, VA 23612
877-557-2672 or 877-LLS-COPAY
Fax: (877) 267-2932 or 877-COPAY-FAX
APPLLS20237600-344347-30-2 APPLLS20237600-344347-30-2

The LLS Co-Pay Assistance Program

Proof of Expenditure Form

Complete this form for each claim you submit to The LLS Co-Pay Assistance Program. Include supporting documents, like
receipts, with the form. To submit the form and documents, you can:
• Upload them in the online portal at: https://cprportal.lls.org/#/login
• Fax them to: (877) 267-2932
• Mail them to: LLS Co-Pay Assistance Program, P.O. Box 12268, Newport News, VA 23612

You can include more than one expense for the same payee (person to be paid) on this form. Check the How to Submit a
Claim sheet in your approval packet for more information. Questions? Call us at: (877) 557-2672

Form Submitted by: _____ Patient ______ Provider ______Pharmacy

Patient Information

Patient's Legal Name: Matt Neal Date of Birth: 11/17/1978

Street Address: 421 SE County Rd

City: Ada State: OK ZIP code: 74820

Award Information

Disease Silo: Lymphoma Grant Amount: $5,000.00

Start Date: 01/18/2023 90-Day Lookback Date: 10/20/2022

*Claim Submission Grace Period Deadline: 04/17/2024 End Date: 01/18/2024

*Claims received after this date will not be processed.
Payment Information

Check Payable to:

Mailing Address:
City: State: ZIP code:

Total Amount Requested: $

Check the statement below that is true for this claim. You can check only one:
I certify that the claim(s) submitted have not been paid by the patient or another organization, and I confirm that
the information submitted with the claim is true, complete, and accurate to the best of my knowledge.
OR
I certify that claim(s) submitted have been paid and receipt(s) are included to support the reimbursement request
and I confirm that the information submitted with the claim is true, complete, and accurate to the best of my knowledge.

Signature: Date:

APPLLS20237600-344347-30-2 APPLLS20237600-344347-30-2
APPLLS20237600-344347-30-2 APPLLS20237600-344347-30-2

The LLS Co-Pay Assistance Program

Proof of Expenditure Form

Complete this form for each claim you submit to The LLS Co-Pay Assistance Program. Include supporting documents, like
receipts, with the form. To submit the form and documents, you can:
• Upload them in the online portal at: https://cprportal.lls.org/#/login
• Fax them to: (877) 267-2932
• Mail them to: LLS Co-Pay Assistance Program, P.O. Box 12268, Newport News, VA 23612

You can include more than one expense for the same payee (person to be paid) on this form. Check the How to Submit a
Claim sheet in your approval packet for more information. Questions? Call us at: (877) 557-2672

Form Submitted by: _____ Patient ______ Provider ______Pharmacy

Patient Information

Patient's Legal Name: Matt Neal Date of Birth: 11/17/1978

Street Address: 421 SE County Rd

City: Ada State: OK ZIP code: 74820

Award Information

Disease Silo: Lymphoma Grant Amount: $5,000.00

Start Date: 01/18/2023 90-Day Lookback Date: 10/20/2022

*Claim Submission Grace Period Deadline: 04/17/2024 End Date: 01/18/2024

*Claims received after this date will not be processed.
Payment Information

Check Payable to:

Mailing Address:
City: State: ZIP code:

Total Amount Requested: $

Check the statement below that is true for this claim. You can check only one:
I certify that the claim(s) submitted have not been paid by the patient or another organization, and I confirm that
the information submitted with the claim is true, complete, and accurate to the best of my knowledge.
OR
I certify that claim(s) submitted have been paid and receipt(s) are included to support the reimbursement request
and I confirm that the information submitted with the claim is true, complete, and accurate to the best of my knowledge.

Signature: Date:

APPLLS20237600-344347-30-2 APPLLS20237600-344347-30-2
APPLLS20237600-344347-30-2 APPLLS20237600-344347-30-2

Leukemia & Lymphoma Society

Co-Pay Assistance Program

PO Box 12268
Newport News, Va 23612
Toll Free: 1-877-557-2672 FAX: 1-877-267-2932

ATTN: LLS Co-Pay Assistance Program From:

COMPANY: Leukemia & Lymphoma Society DATE: 01/18/2023

FAX NUMBER: 1-877-267-2932 TOTAL PAGES WITH COVER:

PHONE: 1-877-557-2672 SENDER’S PHONE:

PATIENT NAME: Matt Neal SENDER’S FAX:

PATIENT ID: 344347

SPECIAL INSTRUCTIONS

When faxing expenditure documents, please use this fax cover sheet.
(ex: Proof of Expenditure form, EOB's, etc.)

The information contained in this transmittal is privileged and confidential, and intended only for the use of the
individual(s) and/or entity(ies) names above. If you are not the intended recipient, you are hereby notified that any
unauthorized disclosure, copying, distribution or taking of any action on the contents of the telecopied materials is
strictly prohibited. If you have received this transmission in error, please immediately notify us by telephone.
Thank you

APPLLS20237600-344347-30-2 APPLLS20237600-344347-30-2