CO-PAY ASSISTANCE

CoverOne provides co-pay assistance for privately-insured BAVENCIO® (avelumab) 20mg/mL patients with co-pay/co-insurance responsibilities who meet the program eligibility criteria. Limits, terms and conditions apply, see below

  • Privately insured patients may apply for assistance through the CoverOne Co-pay Assistance Program by faxing a completed CoverOne Enrollment Form to 1-800-214-7295
  • We are not permitted to offer CoverOne Co-pay Assistance to any claims covered, paid or reimbursed, in whole or in part, by Medicaid, Medicare, or other federal or state healthcare programs.
  • Enrollment in the co–pay assistance program does not guarantee assistance. Whether an expense is eligible for the CoverOne Co-Pay Assistance benefit will be determined at the time the benefit is paid. Eligible co-pay expenses must be in connection with a separately paid claim for BAVENCIO® administered in outpatient setting, which is otherwise covered by a private/commercial insurance plan.
  • Enrolled patients will be responsible for a $10 co-pay/co-insurance, and may be eligible for BAVENCIO co-pay assistance up to a maximum of $30,000 per year.
CO-PAY PROGRAM TERMS AND CONDITIONS

The patient co-pay assistance program is not contingent on any past or commercial sale of BAVENCIO. The co-pay program does not assist with inpatient hospital claims, or in any bundled payment arrangement where there is no separate patient co-pay for BAVENCIO, and does not assist with healthcare premiums or drug administration services.

By enrolling in the CoverOne co-pay program, you acknowledge that you currently meet the eligibility criteria and will comply with the Terms and Conditions described below:

  1. The CoverOne Co-pay program is offered to eligible BAVENCIO (avelumab) Injection patients who are insured through a private/commercial health plan, and are enrolled in CoverOne.
  2. The offer is not valid for medicines that are eligible to be reimbursed, in whole or in part, by Medicaid, Medicare, or other federal or state healthcare programs (including any state prescription drug assistance programs and the Government Health Insurance Plan available in Puerto Rico [formerly known as "La Reforma de Salud"]).
  3. If your insurance status changes, you must notify us immediately.
  4. The offer is not valid for medicines that are eligible to be reimbursed by private insurance plans or other health or pharmacy benefit programs,which reimburse you for the entire cost of your prescription drugs.
  5. You are responsible for $10 or the full amount of your co-pay, whichever is less, for each treatment for BAVENCIO. The amount of any assistance is the difference between your co-pay and $10. You are entitled to maximum assistance of $30,000 per year per patient.
  6. You must deduct the value received under this program from any reimbursement request submitted to your insurance plan, either directly by you or on your behalf.
  7. Cannot be combined with any other rebate/coupon, free trial, or similar offer for the specified medicine. This offer is not health insurance.
  8. The CoverOne Copay Program Offer is good only in the United States and US Territories.
  9. The CoverOne Copay-Card is only available at participating medical facilities, or pharmacies.
  10. EMD Serono and Pfizer Inc. reserve the right to rescind, revoke, or amend the program without notice at any time.
  11. No membership fees.
  12. The copay program offer is limited to 1 per person during this offering period and is not transferable.
  13. In order to receive copay program assistance after enrollment, the patient or provider must submit an Explanation of Benefits form. The submitted EOB must include the name of the insurer, plan information, and show that BAVENCIO was administered in an outpatient setting and paid separately. If the EOB indicates that the patient does not meet the eligibility criteria, including the criteria described in 1 & 2, above, co-pay assistance will not be payable. Claims must be submitted to CoverOne within 180 days of the date of the EOB from your primary insurance company.
  14. Expiration date: 12/31/2018.
  15. The CoverOne Co-Pay Program is not available where prohibited by law. Once enrolled, you will receive a copay program debit card. Please refer to the CoverOne Co-pay Claim Submission Instructions for additional information.