Terms and Conditions
This Evrysdi Co-pay Program is valid ONLY for patients with commercial (private or non-governmental) insurance who have a valid prescription for a Food and Drug Administration (FDA)-approved indication of a Genentech medication. Patients using Medicare, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DoD), TRICARE or any other federal or state government program (collectively, "Government Programs") to pay for their medications are not eligible. The program is not valid for medications that are eligible to be reimbursed in their entirety by private insurance plans or other programs.
Under the program, the patient will pay a co-pay. After reaching the maximum program benefit, 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 the drug fees associated with Evrysdi. The program benefit will reset every January 1st. This program is not health insurance or a benefit plan. The program does not obligate the use of any specific product or provider. Patients receiving assistance from charitable free medicine programs (such as the Genentech Patient Foundation) or any other charitable organizations for the same expenses covered by the program are not eligible. The co-pay benefit cannot be combined with any other rebate, free trial or similar offer for the medication. No party may seek reimbursement for all or any part of the benefit received through this program.
The program may be accepted by participating pharmacies, physicians' offices or hospitals. Once a patient is enrolled, this program will not honor claims with date of service or medication dispensing that precede program enrollment date by more than 180 days. Claims must be submitted within 365 days from the date of service unless otherwise indicated. Use of this program must be consistent with all relevant health insurance requirements. Participating patients, pharmacies, physician offices and hospitals are responsible for reporting the receipt of all program benefits as required by any insurer or by law. Program benefits may not be sold, purchased, traded or offered for sale.
The patient or their guardian must be 18 years or older to receive program assistance. This program is only valid in the United States and U.S. Territories. This program is void where prohibited by law and shall follow state restrictions in relation to AB-rated generic equivalents (e.g., MA, CA) where applicable. Eligible patients will be automatically re-enrolled in the program on an annual basis. Eligible patients will be removed from the program after 3 years of inactivity (e.g., no claims submitted in a 3-year timeframe). Program eligibility and automatic re-enrollment are contingent upon the patient's ability to meet all requirements set forth by the program. Healthcare providers may not advertise or otherwise use the program as a means of promoting their services or Genentech's products to patients. Genentech reserves the right to rescind, revoke or amend the program without notice at any time.