*Eligibility Criteria: Subject to program limitations and terms and conditions, the AVSOLA™ Co-Pay Card is open to patients who have been prescribed AVSOLA™ and who have commercial or private insurance, including plans available through state and federal healthcare exchanges. This program helps eligible patients cover out-of-pocket medication costs related to AVSOLA™, up to program limits. The AVSOLA™ Co-Pay Card does not cover any other costs related to office visits or administration of AVSOLA™. There is no income requirement to participate in this program.
This offer is not valid for patients whose AVSOLA™ prescription is paid for in whole or in part by Medicare, Medicaid, or any other federal or state healthcare program. It is not valid for cash-paying patients or where prohibited by law. A patient is considered cash-paying where the patient has no insurance coverage for AVSOLA™ or where the patient has commercial or private insurance but Amgen in its sole discretion determines the patient is effectively uninsured because such coverage does not provide a material level of financial assistance for the cost of an AVSOLA™ prescription.
- PROGRAM BENEFITS
The AVSOLA™ Co-Pay Card does not cover out-of-pocket costs for any patient whose selected coverage option under their commercial insurance plan does not apply AVSOLA™ Co-Pay Card payments to satisfy the patient’s co-payment, deductible, or co-insurance for AVSOLA™. Patients with these plan limitations are not eligible for the AVSOLA™ Co-Pay Card but may be eligible for other needs-based assistance provided by Amgen. These programs are often referred to as accumulator adjustment programs. If you believe your commercial insurance plan may have such limitations, please contact AVSOLA™ Support at 1-866-264-2778.
The AVSOLA™ Co-Pay Card also may provide a reduced benefit amount, unilaterally determined by Amgen in its sole discretion, to satisfy the out-of-pocket cost sharing requirement for any patient whose plan or plan agent (including, but not limited to, a Pharmacy Benefit Manager (PBM)) requires enrollment in the AVSOLA™ Co-Pay Card as a condition of the plan or PBM waiving some or all of an otherwise applicable patient out-of-pocket cost sharing amount. These programs are often referred to as co-pay maximizer programs. If you believe your commercial insurance plan may have such limitations, please contact AVSOLA™ Support at 1-866-264-2778. Health plans, Specialty pharmacies, and Pharmacy Benefit Managers (individually and collectively “Plan Administrators”) are prohibited from enrolling patients in the AVSOLA™ Co-Pay Card. Plan Administrators are prohibited from assisting patients with enrollment in the AVSOLA™ Co-Pay Card. The patient, or his/her legal representative, must personally enroll in the AVSOLA™ Co-Pay Card in order to be eligible for program benefits.
If at any time a patient begins receiving coverage for medications under any federal, state, or government healthcare program (including but not limited to Medicare, Medicaid, TRICARE, Department of Defense, or Veteran Affairs programs), the patient will no longer be able to use this card and you must contact AVSOLA™ Support at 1-866-264-2778 (Monday through Friday, from 9:00 am to 8:00 pm ET) to stop your participation in this program.
Patients may not seek reimbursement for the value received from the AVSOLA™ Co-Pay Card from any third-party payers, including a flexible spending account or healthcare savings account. Participating in this program means that you are ensuring you comply with any required disclosure regarding your participation in the AVSOLA™ Co-Pay Card of your insurance carrier or pharmacy benefit manager. Restrictions may apply. Offer subject to change or discontinuation without notice. This is not health insurance.
- PROGRAM DETAILS
For all eligible patients the AVSOLA™ Co-Pay Card offers:
- A program benefit that covers the patient’s eligible out-of-pocket medication costs for AVSOLA™ (co-pay, deductible, or co-insurance) on behalf of the patient, up to a Maximum Program Benefit determined by the program per calendar year. The AVSOLA™ Co-Pay Card does not cover any other costs related to office visits or administration of AVSOLA™.
- AVSOLA™ patients pay $5 out-of-pocket for each treatment, and Amgen will pay on behalf of the patient the remaining eligible out-of-pocket prescription costs (up to the Patient Total Program Benefit described below. AVSOLA™ patients are responsible for all amounts that exceed this limit.).
- Ongoing activation of the AVSOLA™ Co-Pay Card is contingent on the submission of the required Explanation of Benefits (EOB) form by the healthcare provider’s office within 180 days of the use of the AVSOLA™ Co-Pay Card. Patients will be responsible for reimbursing the program for all amounts paid out if the EOB for the date of service is not received within 180 days.
Maximum Program Benefit, Patient Total Program Benefit, Benefits May Change, End or Vary: The program provides up to a Maximum Program Benefit of assistance to reduce a patient’s out-of-pocket medication costs that Amgen will provide per patient for each calendar year, which must be applied to the AVSOLA™ patient’s out-of-pocket costs (co-pay, deductible, or co-insurance). Patient Total Program Benefit amounts are unilaterally determined by Amgen in its sole discretion and will not exceed the Maximum Program Benefit. The Patient Total Program Benefit may be less than the Maximum Program Benefit, depending on the terms of a patient’s plan, and may vary among individual patients covered by different plans, based on factors determined solely by Amgen, to ensure all programs funds are used for the benefit of the patient. Each patient is responsible for costs above the Patient Total Program Benefit amounts. Please ask your AVSOLA™ Support Representative to help you understand whether your particular insurance coverage is likely to result in your reaching the Maximum Program Benefit or your Patient Total Program Benefit amount by calling 1-866-264-2778. Participating patients are solely responsible for updating Amgen with changes to their insurance including, but not limited to, initiation of insurance provided by the government, the addition of any coverage terms that do not apply AVSOLA™ Co-Pay Card benefits to reduce a patient’s out-of-pocket costs, such as accumulator adjustment benefit design or a co-pay maximization program. Participating patients are responsible for providing Amgen with accurate information necessary to determine program eligibility. By accepting payments from Amgen made on behalf of participating patients, participating PBMs and Plans likewise are responsible for providing Amgen with accurate information regarding patient eligibility.
Patients may use the card every time they receive a treatment with AVSOLA™. Benefits reset each calendar year. Enrollment in the program is for 12 months. Patients may participate in the program for 12 months, or continue in the program after that, provided s/he continues to meet all of the program’s eligibility requirements during participation in the program, and with program enrollment renewal every 12 months. Patients can enroll/reenroll by calling 1-866-264-2778.
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