ZEPOSIA 360 Support

Eligibility and Terms and Conditions

Co-pay Program (Drug)

ZEPOSIA Prescription Co-pay Card Program is valid only for patients with commercial insurance. The Program includes a prescription benefit offer for out-of-pocket drug costs where the full cost of the ZEPOSIA prescription is not covered by patient’s insurance. Patients are not eligible for the Program if they have prescription insurance coverage through a state or federal healthcare program, including but not limited to Medicare, Medicaid, Medigap, CHAMPVA, TRICARE, Veterans Affairs (VA), or Department of Defense (DoD) programs. Patients who move from commercial plans to state or federal healthcare programs will no longer be eligible. Patient must be 18 years of age or older. Eligible patients with an activated co-pay card and a valid prescription may pay as little as $0 per 30-day supply; monthly, annual, and/or per-claim maximum program benefits may apply and vary from patient to patient, depending on the terms of a patient’s prescription drug plan and to ensure that the funds are used for the benefit of the patient, based on factors determined solely by Bristol-Myers Squibb. Some prescription drug plans have established programs referred to as “co-pay maximizer” programs. A co-pay maximizer program is one in which the amount of the patient’s out-of-pocket costs is adjusted to reflect the availability of support offered by a co-pay support program. Patients enrolled in co-pay maximizer programs may receive program benefits that vary over time to ensure the program funds are used for the benefit of the patient. Patients will be evaluated for ongoing eligibility to continue enrollment in the program. In the event patients experience a change in insurance coverage or BMS makes changes to the copay assistance program, patients may be required to re-enroll into the program and provide updated insurance information to determine eligibility. All Program payments are for the benefit of the patient only. Patients, pharmacists, and prescribers may not seek reimbursement from health insurance, health savings or flexible spending accounts, or any third party, for any part of the prescription benefit received by the patient through this Program. Patient’s acceptance of any Program benefit confirms that it is consistent with patient’s insurance and that patient will report the value received as may be required by his/her insurance provider. Program valid only in the United States and Puerto Rico. Void where prohibited by law, taxed, or restricted. The Program cannot be combined with any other offer, rebate, coupon, or free trial. The Program is not conditioned on any past, present or future purchase, including refills. The Program is not insurance. Other limitations may apply. Bristol Myers Squibb reserves the right to rescind, revoke, or amend this Program at any time without notice.

ZEPOSIA Medical Reimbursement Benefit Program

ZEPOSIA Medical Reimbursement Benefit Program is valid only for patients with commercial insurance. The Program includes a medical assessment benefit offer for out-of-pocket costs for the initial blood tests, ECG screening, and eye exam for ZEPOSIA where the full cost is not covered by patient’s insurance. Patients are not eligible for the Program if they have insurance coverage for their medical assessment through a state or federal healthcare program, including but not limited to Medicare, Medicaid, Medigap, CHAMPVA, TRICARE, Veterans Affairs (VA), or Department of Defense (DoD) programs, or reside in Massachusetts, Minnesota or Rhode Island. Patients who move from commercial plans to state or federal healthcare programs will no longer be eligible. Patient must be 18 years of age or older. Eligible commercially insured patients may pay as little as $0 in out-of-pocket costs for the medical assessment, subject to a maximum benefit of $2,000. The Program offer only applies to ZEPOSIA clinical baseline assessment services covered by the Program. Patients are responsible for any costs that exceed the maximum amount. To receive the medical assessment benefit, an Explanation of Benefits (EOB) form must be submitted, along with copies of receipts for any payments made. All Program payments are for the benefit of the patient only. Patients, pharmacists, and prescribers may not seek reimbursement from health insurance, health savings or flexible spending accounts, or any third party, for any part of the medical assessment benefit received by the patient through this Program. Patient’s acceptance of any Program benefit confirms that it is consistent with patient’s insurance and that patient will report the value received as may be required by his/her insurance provider. Program valid only in the United States and Puerto Rico. Void where prohibited by law, taxed, or restricted. The Program cannot be combined with any other offer, rebate, coupon, or free trial. The Program is not conditioned on any past, present or future purchase, including refills. The Program is not insurance. Other limitations may apply. Bristol Myers Squibb reserves the right to rescind, revoke, or amend this Program at any time without notice.

Combined Co-pay Programs (Drug and Medical Benefit)

ZEPOSIA Co-pay Program is valid only for patients with commercial insurance. The Program includes a prescription benefit offer for out-of-pocket drug costs and a medical assessment benefit offer for out-of-pocket costs for the initial blood tests, ECG screening, and eye exam where the full cost is not covered by patient’s insurance. Patients are not eligible for the prescription benefit offer if they have prescription insurance coverage through a state or federal healthcare program, including but not limited to Medicare, Medicaid, Medigap, CHAMPVA, TRICARE, Veterans Affairs (VA), or Department of Defense (DoD) programs. Patients are not eligible for the medical assessment benefit offer if they have insurance coverage for their prescription or medical assessment through a state or federal healthcare program, or reside in Massachusetts, Minnesota or Rhode Island. Patients who move from commercial plans to state or federal healthcare programs will no longer be eligible. Patient must be 18 years of age or older. Eligible patients with an activated co-pay card and a valid prescription may pay as little as $0 per 30-day supply; monthly, annual, and/or per-claim maximum program benefits may apply and vary from patient to patient, depending on the terms of a patient’s prescription drug plan and to ensure that the funds are used for the benefit of the patient, based on factors determined solely by Bristol-Myers Squibb. Some prescription drug plans have established programs referred to as “co-pay maximizer” programs. A co-pay maximizer program is one in which the amount of the patient’s out-of-pocket costs is adjusted to reflect the availability of support offered by a co-pay support program. Patients enrolled in co-pay maximizer programs may receive program benefits that vary over time to ensure the program funds are used for the benefit of the patient. Patients will be evaluated for ongoing eligibility in the prescription copay program to continue enrollment in the program. In the event patients experience a change in insurance coverage or BMS makes changes to the copay assistance program, patients may be required to re-enroll into the program and provide updated insurance information to determine eligibility. Eligible commercially insured patients may pay as little as $0 in out-of-pocket costs for the medical assessment, subject to a maximum benefit of $2,000. The medical benefit offer only applies to clinical baseline assessment services covered by the Program. Patients are responsible for any costs that exceed the maximum amounts. To receive the medical assessment benefit, an Explanation of Benefits (EOB) form must be submitted, along with copies of receipts for any payments made. All Program payments are for the benefit of the patient only. Patients, pharmacists, and prescribers may not seek reimbursement from health insurance, health savings or flexible spending accounts, or any third party, for any part of the prescription or medical assessment benefit received by the patient through this Program. Patient’s acceptance of any Program benefit confirms that it is consistent with patient’s insurance and that patient will report the value received as may be required by his/her insurance provider. Program valid only in the United States and Puerto Rico. Void where prohibited by law, taxed, or restricted. The Program cannot be combined with any other offer, rebate, coupon, or free trial. The Program is not conditioned on any past, present or future purchase, including refills. The Program is not insurance. Other limitations may apply. Bristol Myers Squibb reserves the right to rescind, revoke, or amend this Program at any time without notice.

ZEPOSIA Free Trial Offer

Patient must have a valid prescription for ZEPOSIA for an FDA-approved indication. Patient must be new to therapy and have not previously received a sample or filled a prescription for ZEPOSIA. Patient is responsible for applicable taxes, if any. This offer is limited to one use per patient per lifetime and is non-transferable. Cannot be combined with any other rebate/coupon, free trial, or similar offer. No substitutions permitted. Patients, pharmacists, and prescribers cannot seek reimbursement for the ZEPOSIA Free Trial from health insurance or any third party, including state or federally funded programs. Patients may not count the ZEPOSIA Free Trial as an expense incurred for purposes of determining out-of-pocket costs for any plan, including Medicare Part D true out-of-pocket costs (TrOOP). Offer is not conditioned on any past, present, or future purchase, including refills. Only valid in the United States and US Territories. Void where prohibited by law or restricted. The program is not insurance. Bristol Myers Squibb reserves the right to rescind, revoke, or amend this offer at any time without notice.

ZEPOSIA In-Home Medical Services Program

Patient must have a valid prescription for ZEPOSIA for an FDA-approved indication. Patients are not eligible if they have prescription insurance coverage through a state or federal healthcare program, including but not limited to Medicare, Medicaid, Medigap, CHAMPVA, TRICARE, Veterans Affairs (VA), or Department of Defense (DoD) programs, or reside in Rhode Island. To receive the In-Home Medical Services Program, the prescriber must request in-home assessment assistance through the ZEPOSIA 360 Support program. The patient’s insurance will not be billed, and the patient will not be responsible for any out-of-pocket costs. Patients who move from commercial plans to state or federal healthcare programs will no longer be eligible. The program cannot be combined with any other offer, rebate, coupon, or free trial. The program is not conditioned on any past, present, or future purchase, including refills. Only valid in the United States and US Territories. Void where prohibited by law, taxed, or restricted. The program is not insurance. Bristol-Myers Squibb Company reserves the right to rescind, revoke, or amend this program at any time without notice. Other limitations may apply.

Bridge Program

The Bridge Program is available at no cost for eligible, commercially insured, on-label diagnosed patients if there is a delay in determining whether commercial prescription coverage is available, and is not contingent on any purchase requirement, for up to 24 months (dispensed in 30-day increments). The Bridge Program is not available to patients who have prescription insurance coverage through a state or federal healthcare program, including but not limited to Medicare, Medicaid, Medigap, CHAMPVA, TRICARE, Veterans Affairs (VA), or Department of Defense (DoD) programs. Appeal of any prior authorization denial must be made within 90 days or as per payer guidelines, to remain in the program. Eligibility will be re-verified in January for patients continuing into the following year, and may be at other times during program participation. Offer is not health insurance. Once coverage is approved by the patient’s commercial insurance plan, the patient will no longer be eligible. Void where prohibited by law, taxed, or restricted. Bristol-Myers Squibb Company reserves the right to rescind, revoke, or amend this program at any time without notice. Other limitations may apply.

ECG=electrocardiogram.