The copay card is non-transferable, limited to one per person,Īnd cannot be combined with any other offer or discount. This offer is not conditioned on any past, present or future purchase, including refills. 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. KevzaraConnect® reserves the right to rescind, revoke, terminate, or amend this offer, eligibility, and terms and conditions at any time without notice. In those situations, the Program may change its terms. Patients may have insurance plans that attempt to dilute the impact of the assistance available under the Program. The Program is intended to help patients afford KEVZARA. CopayĪmounts after applying copay assistance may depend on the patient’s insurance plan and may vary. The maximum annual patient benefit under the Program is $15,000. General, non-product specific insurance deductiblesĪbove the amount set forth above are also not covered. Procedures, or any physician-related services associated with KEVZARA. It is not an insurance benefit, and does not cover or provide support for supplies, Submitted for reimbursement under Medicaid, Medicare, VA, DOD, TRICARE, or similar federal or state programs includingĪny state pharmaceutical assistance program. This offer is not valid for prescriptions covered by or The District of Columbia, and Puerto Rico, are prescribed KEVZARA® (sarilumab) for an FDA-approved indication,Īnd are insured and covered by a commercial health plan. *This program only applies to patients who are at least 18 years of age, residents of the 50 United States, I also understand that the services may be revised, changed, or terminated at any time. 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 ( 1-84), Option 1, or by sending a letter to KevzaraConnect, PO Box 2914, Phoenix, AZ 85062-2914. 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 understand that I may be contacted by the Alliance in the event that I report an adverse event. 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 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 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 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 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.

Xeljanz copay card