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I am enrolling in the KevzaraConnect® Program (the “Program”) and authorize Regeneron PharmaceuticaIs, Inc., Sanofi US, and their agents (together the “Alliance”) to provide me services under the Program, and as may be added in the future. Such services may include medication and adherence communications and support, medication dispensing support, coverage and financial assistance support, disease and medication education, injection training and other support services (the “Services”).
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 Alliance to contact me by mail, telephone, or email, or, if I indicate my agreement and consent below, with information about the Program, rheumatoid arthritis and 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, 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 do not have to enroll in the Program or receive the Communications, and that I can still receive KEVZARA, as prescribed by my physician. I may opt out of receiving Communications, individual support services offered by the Program, including the KevzaraConnect® Copay Card, or opt out of the Program entirely at any time by notifying a Program representative by telephone at 1-844-KEVZARA (1-844-538-9272). 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. 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.
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 1-844-218-0444.
Pharmacist: When you process this card, you are certifying that you have read, understood, and are in compliance with the terms and conditions pertaining to this program. You are further certifying that you have not submitted and will not submit a claim for reimbursement under Medicaid, Medicare, VA, DOD, TRICARE, or similar federal or state programs including any state medical pharmaceutical assistance program for this prescription.
Pharmacist Instructions for a Patient with an Eligible Third Party: Submit the claim to the primary Third-Party Payer first, then submit the balance due to CHANGE HEALTHCARE as a Secondary Payer coordination of benefits with patient responsibility amount and a valid Other Coverage Code (e.g., 8). Maximum reimbursement limits apply; patient out-of-pocket expense may vary. Reimbursement will be received from CHANGE HEALTHCARE.
For any questions regarding CHANGE HEALTHCARE online processing, please call the Help Desk at 1-800-422-5604. The card is not transferable and the amount of the rebate cannot exceed the patient’s out-of-pocket expenses. Program managed by ConnectiveRX, LLC on behalf of Sanofi and Regeneron Pharmaceuticals. Product dispensed pursuant to program rules and federal and state laws. The parties reserve the right to amend or end this program at any time without notice.