I agree to my enrollment in the KevzaraConnect® Copay Card program if confirmed as eligible, understand that Copay Card information will be sent to my designated specialty pharmacy/in-network specialty pharmacy along with my prescription, and any assistance with my applicable cost-sharing or co-payment for KEVZARA (sarilumab) will be made in accordance with the Program terms and conditions.
I authorize the Sanofi US, Regeneron Pharmaceuticals, Inc., affiliates and their agents (together the “Alliance“) to contact me by mail, telephone, or email, with information about KevzaraConnect (the “Program“), rheumatoid arthritis (RA), products, promotions, services and research studies, and to ask my opinion about such information and topics, including market research and disease-related surveys. I further authorize the Alliance to de-identify my health information and use it in performing research including linkage with other de-identified information the Alliance receives from other sources, education, business analytics, marketing studies or for other commercial purposes. I understand that members of the Alliance may share identifiable health information with one another in order to de-identify it for these purposes and as needed to perform the Services or to send the communications listed above (the “Communications“). I understand and agree that the Alliance may use my health information for these purposes and may share my health information with my doctors, specialty pharmacies, and insurers. I understand that I may be contacted by the Alliance in the event that I report an adverse event.
I understand that I do not have to enroll in the KevzaraConnect® Copay Program or receive the Communications, and that I can still receive KEVZARA (sarilumab) injection, as prescribed by my physician. I may opt out of receiving Communications, or opt out entirely at any time by notifying a Program representative by telephone at 1-844-KEVZARA
(1-844-538-9272), Option 1, or by sending a letter to KevzaraConnect, PO Box 2914, Phoenix, AZ 85062-2914. I also understand that the services may be revised, changed, or terminated at any time.
Copay terms and conditions
*This program only applies to patients who are at least 18 years of age, residents of the 50 United States,
the District of Columbia, and Puerto Rico, are prescribed KEVZARA® (sarilumab) for an FDA-approved indication,
and are insured and covered by a commercial health plan. This offer is not valid for prescriptions covered by or
submitted for reimbursement under Medicaid, Medicare, VA, DOD, TRICARE, or similar federal or state programs including
any state pharmaceutical assistance program. It is not an insurance benefit, and does not cover or provide support for supplies,
procedures, or any physician-related services associated with KEVZARA. General, non-product specific insurance deductibles
above the amount set forth above are also not covered. The maximum annual patient benefit under the Program is $15,000. Copay
amounts after applying copay assistance may depend on the patient’s insurance plan and may vary. The Program is intended to help patients afford KEVZARA.
Patients may have insurance plans that attempt to dilute the impact of the assistance available under the Program. In those situations, the Program may change its terms.
KevzaraConnect® reserves the right to rescind, revoke, terminate, or amend this offer, eligibility, and terms and conditions at any time without notice.
Patients, pharmacists, and prescribers cannot seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this offer.
This offer is not conditioned on any past, present or future purchase, including refills. The copay card is non-transferable, limited to one per person,
and cannot be combined with any other offer or discount. This program is not valid where prohibited by law, taxed or restricted. Offer has no cash value.
Program is not valid for cash paying customers. Questions or concerns about deductible, copay, or coinsurance amounts or the ability to obtain KEVZARA? Contact KevzaraConnect® at
1-844-KEVZARA
.
Patient Instructions:
KEVZARA must be covered by your commercial insurance. Program is not valid for cash paying customers. If your prescription is covered by
insurance, you may need to notify the insurance carrier of redemption of this copay card. This offer is not valid for prescriptions covered by or submitted for reimbursement under
Medicaid, Medicare, VA, DOD, TRICARE, or similar federal or state programs including any state pharmaceutical assistance program. This program is not valid where prohibited by law.
By redeeming this coupon, you are certifying that (1) you are not a beneficiary of any government funded program as noted above; (2) should you begin receiving prescription benefits
from any government funded program, you will withdraw from this program; and (3) you acknowledge and understand that adherence to the terms and conditions of this offer is necessary
to ensure compliance with laws pertaining to any government funded program. For questions regarding your eligibility or benefits or if you wish to discontinue your participation,
please call
1-844-KEVZARA.
Pharmacist Instructions:
When you use this offer, you are certifying that you have not submitted and will not submit a claim for reimbursement under any federal, state,
or other government programs for this prescription. Pharmacist will comply with his/her obligations when processing the prescription for payment. By using this offer, you agree to the
terms and conditions of this program. Copay cards must be accompanied by a prescription for KEVZARA. If primary commercial prescription insurance exists, input offer information as secondary
coverage and transmit using the COB segment of the NCPDP transaction. Submit transaction to RxC Acquisition Company d/b/a RxCrossroads by McKesson using BIN #610524. Applicable discounts
will be displayed in the transaction response. Acceptance of this offer and your submission of claims are subject to the Terms and Conditions posted at
www.mckesson.com/mprstnc
.
For questions regarding setup, claim transmission, patient eligibility or other issues, call the LoyaltyScript® for KEVZARA program at
1-844-KEVZARA
.
BY USING THIS COPAY CARD, YOU AND YOUR PHARMACIST UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS AND TERMS OF USE.
