LIFYORLI Patient Enrollment Form

LIFYORLI SUPPORT™ CASE MANAGER CAN HELP WITH THE FOLLOWING:

• Coverage Support • Quick Start Program • Copay Assistance • Patient Assistance Program • Provide Educational Resources

Patient Information*

Patient Name (First, Last)

Date of Birth

Mobile

Home

Work

Preferred Phone

Mobile

Home

Work

OK to Leave Message?

Yes

Address

City

State

Zip

Preferred Language:

English

Spanish

Other

Caregiver Information (optional)

Contact Caregiver Instead of Patient

Yes

Caregiver Name

Mobile

Home

Work

Preferred Phone

Mobile

Home

Work

OK to Leave Message

Yes

Prescriber Information*

Prescriber Name (First, Last)

NPI

Facility Name

Primary Office Contact Name

Address

City

State

Zip

Office Contact Phone

Office Contact Email

Fax

Clinical Information*

Does the patient have a diagnosis consistent with the FDA-approved indication?

Yes

Patient Diagnosis

ICD-10 Code(s)

Treatment Start Date

# of Prior Treatments

Prior Treatments (including bevacizumab)

Insurance Information*

Attach a copy of both sides of patient’s insurance card(s) (prescription insurance information is preferred)

Uninsured

OR Provide Insurance Information:

Plan Name

Group Number

Policy ID/Member Number

Preferred Specialty Pharmacy (select one)*

In-Office or Hospital/Health System Pharmacy Name

Phone

Fax

Authorized In-Network Pharmacy (Onco360 Specialty Pharmacy)

Healthcare Provider (HCP) Consent*

I have read and agree to the Healthcare Provider Certification.

HCP Name (print)

HCP Signature

Date

Patient Authorization

Quick Start Program Prescription (Optional – complete this section only for Quick Start prescription)

LIFYORLI™ (relacorilant) Quick Start Program*

LIFYORLI™ (relacorilant) Quick Start Program offers up to two months of LIFYORLI at no cost for eligible patients who experience a delay in obtaining LIFYORLI™ (relacorilant) Quick Start Program offers up to two months of LIFYORLI at no cost for eligible patients who experience a delay in obtaining coverage from their insurance.

Eligibility Criteria:

Be prescribed LIFYORLI for an FDA-approved use
Live in the US or a US Territory
Have prescription drug insurance
Experience a delay in getting a coverage decision from insurance (≥5 days) and
Be working with insurance to get a coverage decision
Eligible patients will receive one 28-day supply as prescribed by their healthcare provider. If there is a further delay in coverage, patients may receive another 28-day supply refill.

Separate Prescription is attached OR

Complete prescription information section

Patient Name

Date of Birth

Current Medications

Alergies To Medications

LIFYORLI (relacorilant)

Directions for Administration – Recommended Dose

SIG: Take 150 mg PO at the same time of day with food and glass of water the day before, the day of, and the day after each nab-pac (PACLitaxel Protein-Bound Particles) infusion which is given on Day 1, Day 8, and Day 15 of a 28-day cycle.

Dosage Strength: 150 mg Days Supply: 28 (9 Dose Pack) Refills:

Note to pharmacist: When combined with LIFYORLI, nab-paclitaxel is dosed approximately 80 mg/m² IV over 30 minutes on Days 1, 8, and 15 of each 28-day cycle.

Additional Instructions

NOTE: LIFYORLI will be delivered to the patient's address that has been provided.

Prescriber Name (print)

Prescriber Signature

Date

Patient Assistance Program Prescription (Optional - only required if applying for Patient Assistance Program)

Corcept Patient Assistance Program (PAP)*

The Corcept PAP is a charitable program that provides LIFYORLI™ at no cost to patients who need financial assistance and meet eligibility requirements.

Eligibility Criteria:

To qualify to receive LIFYORLI at no cost through the Corcept Patient Assistance Program (Corcept PAP), patients must meet the following eligibility criteria:
Be prescribed LIFYORLI
Live in the US or a US Territory
Have no insurance or have insurance that doesn’t fully cover LIFYORLI
Be unable to afford the cost of LIFYORLI
Have no other financial support available (must not be eligible for Medicare Extra Help, State’s Medicaid or any other financial support options)

Meet the household income limits for the program:

Number of People in Household	Maximum Annual Household Income Allowed ^†
1	$79,800
2	$108,200
3	$136,600
4	$165,000

If your household income is at or below the amount listed for your household size, you may be able to qualify.

* Full Terms and Conditions apply

† These limits are based on federal guidelines. To learn more, visit www.aspe.hhs.gov/poverty

Separate Prescription is attached OR

Complete prescription information section

Patient Name

Date of Birth

Current Medications

Allergies To Medications

LIFYORLI (relacorilant)

Directions for Administration – Recommended Dose

Dosage Strength: 150 mg Days Supply: 28 (9 Dose Pack) Refills:

Note to pharmacist: When combined with LIFYORLI, nab-paclitaxel is dosed approximately 80 mg/m² IV over 30 minutes on Days 1, 8, and 15 of each 28-day cycle.

Additional Instructions

NOTE: LIFYORLI will be delivered to the patient's address that has been provided.

Prescriber Name (print)

Prescriber Signature

Date

Healthcare Provider Certification

HCP should sign in the Healthcare Provider (HCP) Consent section above to provide certification.

The above therapy (or medicine) is medically necessary;

I certify that I am the prescriber who has prescribed LIFYORLI™ and that the information provided is accurate to the best of my knowledge;

I understand that Corcept and its affiliates will use this information to assess the patient’s eligibility for participation in LIFYORLI patient support programs and resources;

For Pharmacy Triage: I authorize LIFYORLI Support to act on my behalf for the purpose of transmitting this prescription to the appropriate pharmacy designated by the patient utilizing their benefit plan (if applicable).

I have not received, nor will I seek or accept reimbursement from any federal, state, or private payers for any drug provided for my patient by either the Quick Start or the Patient Assistance Program (PAP);

I understand that changes to my patient’s insurance or financial status may impact their program eligibility and I agree to notify LIFYORLI Support if I become aware of any such changes;

HCP should sign in the Healthcare Provider (HCP) Consent section above to provide certification.