Lilly PatientOne Co-pay Program Terms and Conditions (Effective September 1, 2018)
(1) You have been prescribed one of the following Lilly Oncology medicines covered by the Lilly PatientOne Co-pay Program (“Program”): Alimta®(pemetrexed for injection), Cyramza®(ramucirumab), Erbitux®(cetuximab), Portrazza®(necitumumab), or Lartruvo®(olaratumab) (hereinafter collectively referred to as “prescribed Lilly Oncology medicine”). (2) You have commercial insurance that covers your prescribed Lilly Oncology medicine, but your insurance does not cover the full cost; that is, you have a co-payor coinsurance obligation. (3) You are not participating in any state or federal healthcare program, including, without limitation, Medicaid, Medicare, Medigap, CHAMPUS, DOD, VA, TRICARE, or any state patient, or pharmaceutical assistance program; patients who move from commercial insurance to a state or federal healthcare program will no longer be eligible. (4) You are 18 years of age or older and are receiving your prescribed Lilly Oncology medicine for an FDA-approved use. Please ask your doctor for information about FDA-approved uses. Also see your doctor for the full US Prescribing Information for your prescribed Lilly Oncology medicine. (5) You are a resident of the United States or Puerto Rico.
(6) The patient must first pay a portion of his or her co-pay or coinsurance ($25 for each dose of the patient’s prescribed Lilly Oncology medicine). The Program will cover the remainder of the patient’s co-pay or coinsurance for the prescribed Lilly Oncology medicine, up to a monthly cap of wholesale acquisition cost plus usual and customary fees anda maximum of $25,000 during a 12-month enrollment period. (7) In order to receive Program benefits, the patient or healthcare provider must submit an Explanation of Payment (EOP) form. The submitted form must include the name of the insurer and plan, and show that the prescribed Lilly Oncology medicine was the medication that was administered. (8) For enrolled patients, a claim for reimbursement must be submitted within 180 days of infusion to receive Program benefits. (9) Program benefits are limited to the co-pay or coinsurance costs for doses of the prescribed Lilly Oncology medicine only. The Program will not cover, and shall not be applied toward, the cost of any dosing procedure, any otherhealthcare provider service or supply charges or other treatment costs, or any costs associated with a hospital stay. (10) For enrolled patients, the Program may provide support for doses with a date of service that falls within 120 days prior to the datethe application is received by the Program.
(11) Patients must enroll on or before December 31, 2019, to be eligible to receive benefits. (12) If you live in Massachusetts, the Program co-pay card for a particular Lilly Oncology medicine expires on the earlier of: (i) the expiration date of the Program co-pay card (December 31, 2019);(ii) the date an AB rated generic equivalent becomes available; or (iii) June 30, 2019, absent a change in Massachusetts state law. If you live in California, the card for a particular Lilly Oncology medicine expires on the earlier of:(i) the expiration date of Program co-paycard (December 31, 2019);or (ii) the date an FDA-approved therapeutically equivalent becomes availableor over-the-counter product with the same active ingredients becomes available.
Additional Program Terms and Conditions:
(13) Patients, pharmacists, and healthcare providers must not seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this Program. Patients must not seek reimbursement from any health savings, flexible spending, or other healthcare reimbursement accounts for the amount of assistance received from the Program. (14) Acceptance of this offer confirms that this offer is consistent with your insurance and that you will report the value of the co-pay assistance you receive as may be required by your insurance provider. (15) This offer is not valid with any other financial support program, Patient Assistance Program (PAP), discount, or incentive involving the prescribed Lilly Oncology medicine. (16) Only valid in the United States and Puerto Rico; this offer is void where restricted or prohibited by law. (17) The Program benefits are nontransferable. (18) This offer is not conditioned on any past, present, or future purchase, including additional doses. (19) The Program is not insurance. (20) Lilly USA, LLC reserves the right to terminate, rescind, revoke, or amend this offer at any time without notice.