COPAY ASSISTANCE PROGRAM

Patient Eligibility:

1. U.S. or U.S. Territory residency. Program valid only in the United States and U.S. Territories.
2. Patient must have commercial (private) insurance that covers the medication; but does not cover the full cost of the medication and the patient is responsible for a portion of the cost
3. Patient must be 18 years of age or older, have a valid prescription for the medication, and be receiving the medication for an FDA approved indication.
4. Patient is not eligible if they are uninsured or if they participate in any federal or state health care program, including without limitation Medicare, Medicaid, Tricare, Veterans Health Administration.
5. If the patient’s insurance situation changes, they must immediately notify AVYXASSIST™ as the patient may no longer be eligible to receive copay assistance for the medication if the patient participates in one of the programs noted above.
6. This offer is not valid for cash-paying patients, if the medication is not covered by the patient’s commercial insurance, or where the plan reimburses patients for the entire cost of the medication.

Program Benefits:

1. This offer allows eligible patient with commercial insurance to pay as little as $0 per month in out-of-pocket costs for each date of service submitted for copay assistance and up to a maximum of $25,000 per calendar year in assistance for the medication
2. Patient is responsible for reporting receipt and value of co-pay or coinsurance assistance as may be required by patient’s insurance provider or health plan. Patients must not seek reimbursement from any health care reimbursement accounts or flexible spending accounts. Patients who move from commercial to federal- or state-funded insurance will no longer be eligible for this program.

Program Timing:

1. This offer is subject to expire December 31st of the calendar year.