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. This offer is not valid for medicines that are eligible to be reimbursed this private insurance plans or other health or pharmacy benefit programs, which reimburse you for the entire cost of your prescription drugs.
5. CoverOne may provide co-pay assistance to eligible Bavencio patients up to $30,000 per calendar year. Enrolled patients are responsible for all co-pays and any other balances not covered by the CoverOne co-pay assistance program.
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. This offer 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. Patient must be a US resident.
9. The CoverOne Copay-Card is only available at participating medical facilities, or pharmacies.
10. EMD Serono, Inc. reserves the right to rescind, revoke, or amend the program without notice at any time.
11. There are no membership fees associated with this offer.
12. The Co-Pay Program offer is limited to 1 per person during this offering period and is not transferable.
13. In order to receive co-pay program assistance after enrollment, the patient or provider must submit an Explanation of Benefits form (EOB). The EOB must include the name of the insurer and 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 paragraphs 1 and 2 of this section, 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: 12/31/2024.
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.
16. The CoverOne Co-Pay Assistance Program is entirely for the benefit of eligible patients.