These Terms and Conditions are valid for ZYMFENTRA as of the date published until amended or terminated by Celltrion (“Program Period”). As a condition of participation in the Program, participants understand and agree that Celltrion may, in its sole discretion, limit, rescind, revoke, terminate, or amend the Program at any time, for any reason, without notice. It is the responsibility of participants to review these Terms and Conditions each time before relying on any Program benefits.
The Celltrion CARES™ Co-pay Assistance Program (“Program”) seeks to help Eligible Patients (defined below) with certain out-of-pocket costs (OOP) for ZYMFENTRA. Under the Program, Eligible Patients may pay as little as $5 for ZYMFENTRA for each fill of a one-month prescription. If the pharmacy can fill a 3-month supply, the Eligible Patient may pay no more than $15. The Program is subject to certain limitations set out below, including Qualifying Expenses (defined below), maximum limits, available funding, and patient eligibility requirements or other restrictions. Actual per-prescription savings for Qualifying Expenses may vary, and patients may be responsible for OOP costs not covered under this Program.
To qualify for Program benefits, the patient must meet the following eligibility requirements (“Eligible Patients”):
Have Commercial Insurance: Patient must have and use private/commercial health insurance that provides at least some coverage for ZYMFENTRA. Patients who do not have coverage for ZYMFENTRA or do not elect to use their commercial health plan to cover at least some of the cost of ZYMFENTRA are ineligible for the Program. Additionally, patients are ineligible for the Program where their insurance policy prohibits such co-pay assistance programs. It is the patient’s responsibility to check with their insurance carrier to confirm that their participation in the Program is not inconsistent with insurance carrier’s requirements; including satisfying any conditions imposed by their carrier for participation in the Program.
Not Have Federal or State Health Insurance: Patients are ineligible for the Program if they are covered, in whole or in part, under:
Medicaid (including Medicaid patients enrolled in a qualified health plan purchased through a health insurance exchange marketplace established by a state government or the federal government),
Medicare (Part A or B),
Medicare Part D or Medicare Advantage plan (regardless of whether a specific prescription is covered),
TRICARE, Veterans Affairs healthcare or the Civilian Health and Medical Program (CHAMPVA),
Puerto Rico Government Health Insurance Plan (“Healthcare Reform” formerly known as “La Reforma de Salud”),
A State prescription drug assistance program, or
Any other state or federal medical or pharmaceutical benefit program or pharmaceutical assistance program (collectively, “Government Programs”).
If at any time in the future, a patient begins receiving prescription drug coverage for ZYMFENTRA under any such Government Program(s), the patient is ineligible for the Program and must call Celltrion CARES™ at 1-877-81CONNC (1-877-812-6662) to stop participation in the Program immediately.
Not Self-Pay: The Program is not valid for self-pay or cash-paying patients (i.e., patients without commercial health insurance, patients with health insurance who lack coverage for ZYMFENTRA, or patients who do not seek to use commercial health insurance to pay for ZYMFENTRA under their plan).
Residency and Age: Patient must be 18 years of age or older and reside in the United States or the Commonwealth of Puerto Rico for at least 6 months and live within and under the guidance of a healthcare provider (HCP) within the United States or the Commonwealth of Puerto Rico. Additionally, ZYMFENTRA covered under the Program must originate and be shipped to locations in the United States or the Commonwealth of Puerto Rico.
On-label Prescription: Patient must be under the care of a physician and prescribed ZYMFENTRA for an FDA-approved indication.
Eligible Patients must be enrolled in the Program and meet all Patient Eligibility requirements.
Patients or their duly licensed provider(s), pharmacist(s), caretakers, or legal guardians may complete the Program enrollment process either via the Celltrion CONNECT® Patient Support Program or online through the Celltrion CARES™ website.
Patients, or those enrolling on behalf of the patient agree to provide all required information and legal consents necessary for Program administration by Celltrion CARES™. Anyone enrolling the patient in the Program represents and warrants all information provided is true and accurate as of the date provided.
Celltrion CARES™ will review the application to determine if the patient is eligible for the Program.
If the patient is eligible for the Program, Celltrion CARES™ will provide the Eligible Patient with virtual co-pay card details that can be used to cover the cost of Qualifying Expenses at their dispensing pharmacy.
For OOP costs incurred by Eligible Patients for ZYMFENTRA under their commercial insurance plan before Program enrollment. The Program will cover eligible costs with a look back date not to exceed 90 days prior to the date the Eligible Patient was enrolled in the Program.
Claims must be processed at the point of sale by the pharmacy where the claim originated for the dispense.
Qualifying Expenses: Are those OOP costs incurred by Eligible Patients for ZYMFENTRA under their commercial insurance plan during the Program period, subject to maximum allowable limits. Qualifying Expenses are not valid for ancillary services including office visit charges or medication administration charges even if such costs are associated with the administration of ZYMFENTRA. Enrolled patients are responsible for all co-pays, deductibles, coinsurance, and any other balances not covered by the Program.
Maximum Limit: Is the total maximum limit an Eligible Patient may receive for Qualifying Expenses during the Program calendar year. The maximum limit is set by Celltrion CARES™ and may be subject to change.
Adjustments: Qualifying Expenses may be adjusted if accumulator or maximizer programs are in effect to ensure that the Program is for the sole benefit of the patient.
The co-pay card is limited to one Eligible Patient per application and may only be used by such patient during the Program Period. The co-pay card is void if transferred or substituted to any other person, or if combined with any other co-pay assistance program, free trial, discount, prescription savings card, or other offer. Co-pay cards may also not be offered for sale, sold, purchased, traded, reproduced, counterfeited, or duplicated.
Patient, pharmacy, and provider agree not to seek reimbursement for all, or any part of the benefit received by the patient through the Program and are responsible for reporting receipt of Program benefits to any insurer, health plan, or other third party who pays for or reimburses any part of the medication cost paid for by the Program, as may be required.
Patients must promptly contact Celltrion CARES™ if their insurance coverage changes.
The maximum number of uses per calendar year is 14.
Automatic re-enrollment in 2025 is only for patients who are utilizing the Program.
The Program is not contingent on any past or future commercial sale of ZYMFENTRA or otherwise void where prohibited by law, taxed, or restricted.
Data Use and Consent: Data related to a patient’s participation in the Program may be collected, analyzed, or shared with Celltrion CARES™ for market research and other purposes related to assessing its co-pay assistance programs. Data shared with Celltrion CARES™ for these purposes will be de-identified, meaning it will not identify the patient specifically.
Modification and Termination of Program: Celltrion CARES™ reserves the right to limit, rescind, revoke, terminate, or amend the Program at any time without notice.
Published: March 2024
