ZEPOSIA^® (ozanimod) Co-pay Program Terms and Conditions

• The 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, CHAMPUS, 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 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.
• The Program expires on December 31, 2023
• 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