Terms and Conditions apply. This benefit covers ELAHERE (mirvetuximab soravtansine-gynx). Eligibility: Available only to patients with commercial insurance coverage for ELAHERE who meet eligibility criteria. The form of co-pay assistance, enrollment requirements, and processes may vary. Please call
1-833-ELAHERE for additional information. Co-pay assistance program is not available to patients receiving reimbursement under any federal, state, or government-funded insurance programs (for example, Medicare [including Part D], Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs programs) or where prohibited by law or by the patient’s health insurance provider. If you live or receive treatment in certain states, you may not be eligible. If at any time a patient begins receiving prescription drug coverage under any such federal, state, or government-funded healthcare program, patient will no longer be able to use the ELAHERE Savings Card and patient must call
1-833-ELAHERE to stop participation. Co-pay assistance provided under this program may not be transferred to or utilized for the benefit of third parties, including, without limitation, third-party insurance plans and/or pharmacy benefit managers and their agents. By enrolling in the co-pay assistance program, you agree that this program is intended solely for the benefit of you, the patient. Some health plans have established programs referred to as “accumulator adjustment” or “co-pay maximizer” programs. An accumulator adjustment program is one in which payments made by you that are subsidized by manufacturer assistance do not count toward your deductibles and other out-of-pocket cost sharing limitations. Co-pay maximizers are programs in which the amount of your out-of-pocket costs is increased to reflect the availability of support offered by a manufacturer assistance program. Except where prohibited by applicable state law, if your insurance company or health plan implements either an accumulator adjustment or co-pay maximizer program, you will not be eligible for, and agree not to use, co-pay assistance because these programs are inconsistent with our agreed intent that this program is solely for your benefit. You also agree that you are personally responsible for paying any amount of co-pay required after the savings card is applied. Any out-of-pocket costs remaining after the application of the savings card may not be paid by your health plan, pharmacy benefit programs, or any other program. If you learn your insurance company or health plan has implemented either an accumulator adjustment program or a co-pay maximizer program, you agree to inform AbbVie of this fact by calling
1-833-ELAHERE to discuss alternative options that may be available to support you. You also agree that you are personally responsible for paying any amount of co-pay required after the savings card is applied. Any out-of-pocket costs remaining after the application of the savings card may not be paid by your health plan, pharmacy benefit programs, or any other program. Subject to all other terms and conditions, the maximum annual benefit that may be available solely for the patient’s benefit under the co-pay assistance program is $25,000 per calendar year. The actual application and use of the benefit available under the co-pay assistance program may vary on a monthly, quarterly, and/or annual basis depending on each individual patient’s plan of insurance and other prescription drug costs. This co-pay assistance program is subject to change, reduction in monetary amount, or discontinuation without any notice. AbbVie in its sole discretion may unilaterally reduce or discontinue the maximum annual benefit for any reason. Except where prohibited by applicable law, this includes potential reduction or discontinuation to ensure that co-pay assistance is utilized solely for the patient’s benefit. Patients may not seek reimbursement for value received from the ELAHERE Savings Card Program from any third-party payers, including insurance plans, flexible spending plans or health savings accounts. Co-pay support made available under this program may not be used with any other coupon, discount, prescription savings card, free trial, or other offer (including any program offered by a third-party insurance plan or pharmacy benefit manager, or an agent of either, that adjusts patient cost-sharing obligations). Offer subject to change or discontinuance without notice. Restrictions, including monthly maximums, may apply. This assistance offer is not health insurance. The failure to enforce any provision of these Terms and Conditions does not constitute a waiver by AbbVie of that or any other provision. By utilizing this co-pay assistance program, you hereby accept and agree to abide by these terms and conditions. Any individual or entity who enrolls or assists in the enrollment of a patient in the co-pay assistance program represents that the patient meets the eligibility criteria and other requirements described herein. Further, you agree that you currently meet the eligibility criteria and other requirements described herein every time you use the co-pay assistance program.
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