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CO-PAY SAVINGS SUPPORT PROGRAM TERMS AND CONDITIONS

To receive co-pay assistance for drug or administration co-pay costs, the provider, patient, or caregiver must enroll the eligible individual within 180 days after the date of service for which the subsidy is sought.

Participating patients, pharmacies, physician offices, and hospitals may use Accord’s patient services web portal or fax completed enrollment forms to 1-877-226-6370 to enroll patients.

Under the Co-Pay Savings Program, if a patient incurs a co-pay obligation for the cost of UDENYCA and meets all eligibility requirements, Accord may provide co-pay assistance for up to $15,000 per calendar year. The Co-Pay Savings Program only covers the cost of the drug. It does not cover costs associated with drug administration.

The program benefits will reset every January 1st. Re-enrollment in the program is required at regular intervals. Patients may participate in the program as long as the patient re-enrolls as required by Accord BioPharma and continues to meet all of the eligibility requirements for the program during participation in the program. After reaching the maximum benefit for either program, the patient will be responsible for all remaining out-of-pocket expenses. The amount of the program’s benefits cannot exceed the patient’s out-of-pocket expenses for the cost of UDENYCA.

Patients must have commercial health insurance. Patients with any federal, state, or government-funded healthcare coverage such as Medicare, Medicare Advantage, Medicare Part D, Veterans Affairs, Department of Defense, or Tricare are not eligible for the program.

The documentation required for claim submission, which can include but is not limited to an Explanation of Benefits (EOB) and claim form (e.g., CMS 1500), must be submitted within 365 days of the date that the primary claim was processed by the patient’s insurance to receive the co-pay savings benefit. Exceptions will not be made for claims submitted more than 365 days.

This Co-Pay Savings Program is offered to and intended for the sole benefit of eligible patients and may not be utilized for the benefit of third parties, including, without limitation, third-party payers, pharmacy benefit managers, or the agents of either. The program is not available if the costs are eligible to be reimbursed in their entirety by private insurance plans or other programs. The program is not available for patients receiving assistance from any other third party, including charitable organizations, if assistance is for the same expenses covered by the program.

This program is not health insurance or a benefit plan. Patient and provider agree to not seek reimbursement for any or all of the benefit received by the patient through the Co-Pay Savings Program. Patient and provider are responsible for reporting receipt of Co-Pay Savings Program benefits to any insurer, health plan, or other third party who pays for or reimburses any part of the drug cost, as may be required.

All participants are responsible for reporting the receipt of all program benefits as required by any insurer or by law. The program is only valid in the United States and otherwise void where prohibited by law. Program benefits may not be sold, purchased, traded, or offered for sale. The program does not obligate use of any specific product or provider. Healthcare providers may not advertise or otherwise use the programs as a means of promoting their services or Accord products to patients. Accord reserves the right to rescind, revoke, or amend the program without notice at any time.