Patient profiles

Monoferric Patient Solutions® (MPS) Copay Assistance Program Terms and Conditions:

• Prescribed Monoferric for an on-label diagnosis
• This offer is valid for commercially insured patients only
• All information applicable to the MPS Copay Assistance Program requested on the enrollment form must be provided and all certifications must be signed. Forms that are modified or do not contain all the necessary information will not be eligible for benefits under the MPS Copay Assistance Program
• Depending on insurance coverage, eligible patients receive savings of up to $2000 for Monoferric, up to a maximum savings limit of $4000 annually. Patients must have out-of-pocket costs of over $0 to participate. Patient out-of-pocket expenses for Monoferric may vary
• This offer is not valid for patients enrolled in Medicare, Medicare Advantage, Medicaid, TRICARE, Veteran Affairs healthcare, a state prescription drug assistance program, the Government Health Insurance Plan available in Puerto Rico (formerly known as “La Reforma de Salud”) or any other federal or state healthcare programs
• Patients may not use the MPS Copay Assistance Program if the entire cost of the patient’s Monoferric prescription is reimbursable by their commercial insurance plan or other commercial health or pharmacy benefit programs
• The MPS Copay Assistance Program is valid for the patient’s out-of-pocket cost for Monoferric only. It is not valid for any other out-of-pocket costs (for example, office visit charges or medication administration charges) even if such costs are associated with the administration of Monoferric. Claim for Monoferric must be submitted by provider to patient’s private health insurance separately from other services and products
• The patient’s healthcare professional must submit an explanation of benefits (EOB) statement from the patient’s commercial insurance provider within 120 days of the date of service for the patient to receive assistance under the MPS Copay Assistance Program. No EOB may be submitted more than 90 days after the expiration or [termination date of the program], and the EOB must be for administration of Monoferric prior to the program expiration or termination date. The EOB must reflect the patient’s out-of-pocket cost for Monoferric and submission of the claim by the patient’s physician for the cost of the medication
• Patient enrollment is for the calendar year and each patient may reenroll in the MPS Copay Assistance Program in subsequent years, as needed
• The patient should not participate in the program if his/her insurer or health plan prohibits use of manufacturer coupons/copay assistance
• Patients must be 18 years of age or older to participate in the MPS Copay Assistance Program
• Offer good only in the USA, including Puerto Rico, at participating pharmacies or healthcare providers
• This patient savings under the MPS Copay Assistance Program may not be combined with any other coupon, discount, prescription savings card, free trial, or other offer
• Void if prohibited by law, taxed, or restricted
• The funds provided for a specific patient case are not transferable. The selling, purchasing, trading, or counterfeiting of a patient’s unique account number is strictly prohibited
• This program is not health insurance
• This offer is not conditioned on any past or future purchases
• Data related to your receipt of financial assistance under the MPS Copay Assistance Program may be collected, analyzed, and shared with Pharmacosmos, for market research and other purposes related to assessing Pharmacosmos’s programs. Data shared with Pharmacosmos will be aggregated and deidentified; it will be combined with data related to other program use and will not identify you
• Pharmacosmos Therapeutics Inc. reserves the right to rescind, revoke, or amend this offer without notice
• By redeeming this assistance, you acknowledge that you are an eligible patient and that you understand and agree to comply with the terms and conditions of this offer
• Qualified patients receiving Monoferric will be allowed a 120-day retroactive enrollment period to receive benefits under the program rules