This website is intended for U.S. residents only

Ipsen Journeys logo

This website is intended for U.S. residents only

Enroll Here

Enrollment Form

Instructions for Patients

  • You need to complete Steps 1, 2, 3, 4,* and read Step 9 outlined in purple on the Enrollment Form.
  • Your healthcare provider will complete the steps outlined in green.
  • It’s important to fill out all sections completely to prevent enrollment delays.
  1. Fill out the Patient Information section in Step 1.
  2. Fill out the Insurance Information section in Step 2.
  3. Fill out the IPSEN CARES Copay Program section in Step 3 if requesting copay assistance.
  4. Fill out the Patient Assistance Program (PAP) section in Step 4 if requesting PAP.
  5. Sign the PATIENT AUTHORIZATION AND ADDITIONAL PRODUCT AND SUPPORT INFORMATION box under Step 3 after you read the information in Step 9.

Your healthcare provider will complete the remainder of the form and fax the appropriate pages to IPSEN CARES.

Instructions for Prescribers

  1. Fill out the Prescriber Information sections in Steps 5-8.
  2. Sign and date the PRESCRIBER ATTESTATION at the end of Step 8.
STEP 1: Patient Information
Gender Assigned at Birth
Required if patient is under 18 years of age.
Best Time to Contact
Would you like to receive text messages from Ipsen for the purposes of helping you/the patient participate in IPSEN CARES patient support programs and/or stay on therapy, as described in Step 9, under Additional Product and Support Information? I give permission to Ipsen to contact me by text message for the purposes described in Step 9. Carrier, text, and data rates may apply.
Would you like to receive marketing information from Ipsen as described in Step 9 under Additional Product and Support Information? I give permission to Ipsen to contact me with information via mail, email, phone, or text message, all of which may include marketing, advertisements, disease state awareness materials, and educational material about SOHONOS and programs that support patients. I understand and agree that any information I provide may be used by Ipsen to conduct data analysis and market research, and to develop new programs and resources. Automatic dialing may be used. Carrier, text, and data rates may apply. I understand that I am not required to provide this consent as a condition of purchasing any goods or services.
Is Patient Insured?*
Is Physician a participating Provider?
Does patient have secondary insurance?*
Eligible patients using commercial insurance can save on out-of-pocket Ipsen medication costs. Please see Patient Eligibility & Terms and Conditions.
I attest that I am not enrolled in any health insurance plan from any state or federally funded programs (including, but not limited to, Medicare or Medicaid, VA, DOD, or TRICARE) and agree to the Terms and Conditions of the Copay Program.

IPSEN CARES PATIENT ASSISTANCE PROGRAM APPLICATION
(Required for patients seeking to participate in the Patient Assistance Program)

The Patient Assistance Program (PAP) is designed to provide SOHONOS at no cost to eligible patients. Patients may be eligible to receive free drug if they are experiencing financial hardship and meet financial eligibility criteria, are uninsured or functionally uninsured, residents of the U.S., and received a valid prescription for an on-label use of SOHONOS as supported by information provided in the program application. Eligibility does not guarantee approval for participation in the program. Free SOHONOS provided by the PAP is intended only for the patient named in the application and must not be sold, transferred, or otherwise diverted. Patients must not seek reimbursement for the free drug provided by the PAP. The PAP provides SOHONOS product only, and does not cover the cost of previously purchased product or medical services. The PAP is not insurance. By submitting an application for the PAP, patient agrees to abide by these program terms.

PROOF OF INCOME*

*IPSEN CARES will conduct a soft credit check as part of the process of confirming income and determining eligibility for the program.

THIRD PARTY VERIFICATION AUTHORIZATION

Preferred Method of Contact
Best Time to Contact
If you would like IPSEN CARES to triage the prescription to the SOHONOS limited specialty pharmacy network, complete the prescription information in Step 8.
Preferred Specialty Pharmacy
Was Rx Sent to a Specialty Pharmacy Already?

INDICATION

SOHONOS is indicated for the reduction in volume of new heterotopic ossification in adults and pediatric patients aged 8 years and older for females and 10 years and older for males with fibrodysplasia ossificans progressiva.

PRESCRIBER DOSING REFERENCE SECTION

  • Recommended dosage includes a chronic daily dose, which can be increased for flare-up symptoms
  • For adults and pediatric patients 14 years and older: 
    Recommended dosage is 5 mg once daily, with an increase in dose at the time of a flare-up to 20 mg once daily for 4 weeks, followed by 10 mg once daily for 8 weeks for a total of 12 weeks (20/10 mg flare-up treatment)
  • For pediatric patients under 14 years: Weight-adjusted for daily and flare-up dosing. Recommended daily dosage range from 2.5 to 5 mg. Refer to Table 1 in Full Prescribing Information for complete pediatric dosing
  • Reduce the dose in the event of adverse reactions as appropriate
  • See Section 2 of the Full Prescribing Information for complete dosing instructions

SOHONOS is indicated for the reduction in volume of new heterotopic ossification in adults and pediatric patients aged 8 years and older for females and 10 years and older for males with fibrodysplasia ossificans progressiva.

Complete this section if you would like IPSEN CARES to triage the prescription to a specialty pharmacy or if the patient is seeking enrollment in the PAP.
PRESCRIPTION: SOHONOSTM (palovarotene)
Gender Assigned at Birth

kg

inches

CHRONIC OR ALTERNATE DOSING
Medication
Strength (Select multiple, if applicable)
Dose & Directions
Take

mg

(total daily dose) by mouth daily with food

Quantity/Refills

Quantity: 28-day supply

FLARE UP DOSING (WEEKS 1-4)

*only if necessary for patient
Medication
Strength (Select multiple, if applicable)
Dose & Directions
Take

mg

(total daily dose) by mouth daily with food

Quantity/Refills

Quantity: 28-day supply
Refills: NONE

FLARE UP DOSING (WEEKS 5-12)

*only if necessary for patient
Medication
Strength (Select multiple, if applicable)
Dose & Directions
Take

mg

(total daily dose) by mouth daily with food

Quantity/Refills

Quantity: 28-day supply
Refills: 1

See full Prescribing Information for complete dosing instructions.

PRESCRIBER ATTESTATION

(The Prescriber must sign if this form is to be used as a prescription to be triaged to a specialty pharmacy to enroll the patient for free goods as part of the Patient Assistance Program (PAP), or to enroll a patient for free goods as part of the Temporary Patient Assistance Program (TPAP). If the request is limited to Benefit Verification or Copay Assistance Program support, the Prescriber, or an individual acting at the direction of the Prescriber and involved in the patient’s care, such as an Office Practice Manager, Financial Coordinator, Financial Counselor, Patient Assistance Coordinator, Patient Navigator, Social Worker, Insurance Coordinator, Patient Coordinator, or Patient Care Advocate, may sign this form.)

By signing below, I certify that the therapy referenced in this form is medically necessary. If this form is to be used to enroll a patient in free goods as part of the PAP or Temporary PAP, I certify that the therapy referenced in this form is prescribed consistent with an FDA-approved indication. I certify that a prescription signed by a licensed prescriber is on file for the referenced therapy and that I have received the necessary authorization from the patient and/or the patient’s guardian to release the information herein and medical and/or patient information relating to SOHONOS therapy to Ipsen and its agents or contractors for the purpose of seeking reimbursement for SOHONOS therapy, assisting in initiating or continuing SOHONOS therapy, and/or evaluating the patient’s eligibility for Ipsen’s patient support programs administered by IPSEN CARES. I authorize Ipsen and its agents or contractors to forward a prescription by fax or other delivery mode to the designated pharmacy. I understand that I must comply with applicable state-specific prescription requirements such as e-prescribing, state-specific prescription form, fax language, etc. Non-compliance with state-specific requirements could result in outreach to me. I certify that any medications received by me or on my behalf from Ipsen in connection with any IPSEN CARES program will be used only for the named patient. These medications will not be offered for sale, transfer, or otherwise diverted. Additionally, no claim for reimbursement will be submitted concerning these medications, or any services provided by IPSEN CARES, to any payor, including Medicare, Medicaid, or any other federal or state health insurance program, nor will any medications be returned for credit. If the named patient does not return for therapy, product will be returned to Ipsen. I acknowledge that I have assisted the named patient in enrolling in IPSEN CARES exclusively for purposes of patient care and not in consideration for, expectation of, or actual receipt of remuneration of any sort.

INDICATION

SOHONOS™ is indicated for the reduction in volume of new heterotopic ossification in adults and pediatric patients aged 8 years and older for females and 10 years and older for males with fibrodysplasia ossificans progressiva (FOP).

IMPORTANT SAFETY INFORMATION

WARNING: EMBRYO-FETAL TOXICITY and PREMATURE EPIPHYSEAL CLOSURE IN GROWING PEDIATRIC PATIENTS

  • SOHONOS is contraindicated in pregnancy. SOHONOS may cause fetal harm. Because of the risk of teratogenicity and to minimize fetal exposure, SOHONOS is to be administered only if conditions for pregnancy prevention are met.
  • Premature epiphyseal closure occurs in growing pediatric patients treated with SOHONOS, close monitoring is recommended.

Contraindications

SOHONOS is contraindicated in patients during pregnancy, or with a history of allergy or hypersensitivity to retinoids, or to any component of SOHONOS.

Warnings and Precautions

  • Embryo-Fetal Toxicity: SOHONOS can cause fetal harm and is contraindicated during pregnancy. Advise females of reproductive potential to use an effective method of contraception at least 1 month prior to treatment, during treatment with SOHONOS and for 1 month after the last dose. If a pregnancy occurs during SOHONOS treatment, discontinue treatment immediately and refer the patient to an obstetrician/gynecologist experienced in reproductive toxicity. Patients should be informed not to donate blood during SOHONOS therapy and for 1 week following discontinuation.
  • Premature Epiphyseal Closure in Growing Pediatric Patients: SOHONOS can cause irreversible premature epiphyseal closure and potential adverse effects on growth. Prior to starting treatment with SOHONOS, all growing pediatric patients should undergo baseline assessment of skeletal maturity and continued monitoring until patients reach skeletal maturity or final adult height. If appropriate, temporary or permanent discontinuation may be warranted.
  • Mucocutaneous Adverse Reactions: Dry skin, lip dry, pruritus, rash, alopecia, erythema, skin exfoliation (skin peeling), and dry eye occurred with SOHONOS. Prophylactic measures to minimize risk and/or treat the mucocutaneous adverse reactions are recommended (e.g., skin emollients, sunscreen, lip moisturizers, or artificial tears). Some may require dose reduction or discontinuation. Photosensitivity reactions have been associated with the use of retinoids and may occur with SOHONOS. Precautionary measures for phototoxicity are recommended (use of sunscreens, protective clothing, and use of sunglasses).
  • Metabolic Bone Disorders: Increased risk of radiologically observed vertebral fractures and decreased vertebral bone mineral content and bone density. Periodic radiological assessment of the spine is recommended. Retinoids have been associated with hyperostotic changes (bone spurs) and calcification of tendons or ligaments may occur with SOHONOS.
  • Psychiatric Disorders: New or worsening psychiatric events were reported with SOHONOS including depression, anxiety, mood alterations, and suicidal thoughts and behaviors. Monitor for development of new or worsening psychiatric symptoms during treatment with SOHONOS. Patients and/or caregivers should contact their healthcare provider if new or worsening psychiatric symptoms develop during treatment with SOHONOS.
  • Night Blindness: This may be dose-dependent, making driving a vehicle at night potentially hazardous during treatment. Advise patients to be cautious when driving or operating any vehicle at night and seek medical attention in the event of vision impairment.

Adverse Reactions

The most common adverse reactions (≥ 10%) are dry skin, lip dry, arthralgia, pruritus, pain in extremity, rash, alopecia, erythema, headache, back pain, skin exfoliation (skin peeling), nausea, musculoskeletal pain, myalgia, dry eye, hypersensitivity, peripheral edema, and fatigue.

Drug Interactions

  • CYP3A4 inhibitors may increase SOHONOS exposure. Avoid concomitant use of strong or moderate CYP3A4 inhibitors, as well as grapefruit, pomelo or juices containing these fruits.
  • CYP3A4 inducers may decrease SOHONOS exposure. Avoid concomitant use of strong or moderate CYP3A4 inducers.
  • The use of both vitamin A and SOHONOS at the same time may lead to additive effects. Concomitant administration of vitamin A in doses higher than the recommended daily allowance and/or other oral retinoids must be avoided due to risk of hypervitaminosis A.
  • Systemic retinoid use has been associated with cases of benign intracranial hypertension (pseudotumor cerebri), some of which involved the concomitant use of tetracyclines. Avoid coadministration of SOHONOS with tetracycline derivatives.

Use in Specific Populations

  • Pregnancy: SOHONOS is contraindicated during pregnancy. Obtain a negative serum pregnancy test within 1 week prior to SOHONOS therapy and periodically, as needed, over the course of treatment with SOHONOS and 1 month after treatment discontinuation unless patient is not at risk of pregnancy. If pregnancy occurs during treatment with SOHONOS, stop treatment immediately and refer the patient to an obstetrician/gynecologist or other specialist experienced in reproductive toxicity for evaluation and advice.
  • Lactation: Advise females that breastfeeding is not recommended during treatment with SOHONOS, and for at least 1 month after the last dose.
  • Females and Males of Reproductive Potential: Advise females of reproductive potential to use effective contraception at least 1 month prior to and during treatment, and for 1 month after the last dose unless continuous abstinence is chosen.
  • Pediatric Use: All growing pediatric patients should undergo baseline assessment of growth and skeletal maturity before starting treatment and continued clinical and radiographic monitoring every 6-12 months until patients reach skeletal maturity or final adult height.
  • Renal or Hepatic Impairment: Use of SOHONOS in patients with severe renal impairment, or with moderate or severe hepatic impairment is not recommended.

Please see accompanying full Prescribing Information, including BOXED WARNING.

ADDITIONAL PRODUCT AND SUPPORT INFORMATION

Text Communications

Marketing Information

We are collecting personal information in order to fulfill your request. Please see Ipsen’s privacy policy at https://www.ipsen.com/us/privacy-policy/. Residents of certain states have additional rights regarding the collection, use, and disclosure of their personal information. For more information, please see Ipsen’s Supplemental State Privacy Notice at https://www.ipsen.com/us/Supplement-Website-Privacy-Notice/.

IMPORTANT SAFETY INFORMATION & INDICATION for SOHONOSTM (palovarotene) Capsules

What is the most important information I should know about SOHONOS?

 

SOHONOS can cause birth defects (deformed babies) if taken during pregnancy. Females who are pregnant or who plan to become pregnant must not take SOHONOS.

  • Your healthcare provider will ask you to take a pregnancy test 1 week before starting treatment with SOHONOS, periodically during treatment, and 1 month after you stop treatment.
  • You must use effective birth control (contraception) starting at least 1 month before starting treatment with SOHONOS, during treatment, and for 1 month after the last dose. Talk to your healthcare provider about birth control methods that may be right for you.
  • If you become pregnant or think you may be pregnant during treatment with SOHONOS, stop taking SOHONOS and call your healthcare provider right away.

Because SOHONOS can cause birth defects, SOHONOS is only for people who can understand and agree to carry out all instructions for pregnancy prevention.

SOHONOS can cause bone growth changes. Children may stop growing while taking SOHONOS. Bone growth changes such as permanent early closure of the growth plate in growing children have happened with SOHONOS. Your healthcare provider will closely monitor your child’s bone growth and height during treatment with SOHONOS.

Who should not take SOHONOS?

Do not take SOHONOS if you are pregnant, or allergic to medicines known as retinoids or any of the ingredients in SOHONOS.

What should I tell my healthcare provider before taking SOHONOS?

Before taking SOHONOS, tell your healthcare provider about all your medical conditions, including:

  • have bone loss (osteoporosis), weak bones or any other bone problems
  • have or had mental health problems
  • have or have had kidney problems
  • have or have had liver problems
  • are breastfeeding or plan to breastfeed. It is not known if SOHONOS passes into your breastmilk. Breastfeeding is not recommended during treatment with SOHONOS and for at least 1 month after the last dose of SOHONOS. Talk to your healthcare provider about the best way to feed your baby if you take SOHONOS.

Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. SOHONOS and certain other medicines can interact with each other, sometimes causing serious side effects. Keep a list of your medicines to show to your healthcare provider and pharmacist when you get a new medicine.

What should I avoid while taking SOHONOS?

  • Do not get pregnant while taking SOHONOS.
  • Avoid excessive exposure to sunlight and ultraviolet lights (tanning machines). SOHONOS may make your skin more sensitive to the exposure and you may burn more easily. Apply sunscreen and wear protective clothing and sunglasses when in sunlight.
  • Avoid driving at night until you know if SOHONOS has affected your vision. SOHONOS may decrease your ability to see in the dark.
  • Do not donate blood while taking SOHONOS and for 1 week after stopping SOHONOS.

What are the possible side effects of SOHONOS?

SOHONOS can cause serious side effects, including:

  • skin-related events such as dry skin, lip and eye, hair loss, itching, redness, rash, and skin peeling. You may be at increased risk of developing skin and soft tissue infections while taking SOHONOS. If you develop these symptoms, your healthcare provider may tell you to use moisturizer, sunscreen, or artificial tears.
  • bone mineral density problems (bone thinning) which can increase the risk of fractures in adults and children. Your healthcare provider should check you for this during treatment with SOHONOS.
  • new or worsening mental health problems that may include depression, anxiety, mood changes, and suicidal thoughts and behaviors. If you have a history of mental health problems, you may be at a higher risk of developing these side effects. Call your healthcare provider if you develop new or worsening mental health symptoms during treatment with SOHONOS. Your healthcare provider should monitor you for signs of depression and refer you for appropriate treatment, if necessary.
  • vision problems (night blindness) which may cause difficulty seeing at night or in low lit areas. Your healthcare provider should send you to see an eye specialist if you experience vision problems.

The most common side effects of SOHONOS include:

  • dry skin
  • dry lips
  • hair loss
  • itching
  • redness
  • rash
  • skin peeling
  • drug eruption
  • skin irritation
  • swelling and small cracks in corner of the mouth
  • nausea
  • muscle and joint pain
  • dry eyes
  • headache
  • fatigue

These are not all the possible side effects of SOHONOS. Call your doctor for medical advice about side effects. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

WHAT IS SOHONOS?

SOHONOS is a prescription medicine used to reduce the amount of new heterotopic ossification in adults and children 8 years of age and older for females and 10 years and older for males with fibrodysplasia ossificans progressiva (FOP). SOHONOS is not recommended for females younger than 8 years of age or males younger than 10 years of age.

Please see full Prescribing Information, including Medication Guide with IMPORTANT WARNING.