ZILRETTA CO-PAY PROGRAM TERMS AND CONDITIONS
It is important that patients and Health Care Providers (“HCP”) read and understand the full ZILRETTA Co-Pay Program (the “Program”) Terms and Conditions below.
As further described below, in general:
- The ZILRETTA Co-Pay Program is open to patients with commercial insurance that covers ZILRETTA, regardless of financial need.
- The ZILRETTA Co-Pay Program is not valid for patients whose prescription for ZILRETTA 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. (See ELIGIBILITY section in full Terms and Conditions.)
- The ZILRETTA Co-Pay Program may help lower patient out-of-pocket medication costs for ZILRETTA, which may include co-payment, co-insurance, and deductible out-of-pocket costs. The ZILRETTA Co-Pay Program does not cover any other costs related to office visits or the administration of ZILRETTA. The Program provides support up to the Maximum Program Benefit or Patient Total Program Benefit. If a patient’s commercial insurance plan imposes different or additional requirements on patients who receive Program benefits, Pacira BioSciences, Inc. (“Pacira”) has the right to modify or eliminate those benefits. Whether a patient is eligible to receive the Maximum Program Benefit or Patient Total Program Benefit is determined by the type of plan coverage the patient has. HCPs can reach out to the Program for help to understand a patient’s eligibility, whether the patient’s particular insurance coverage is likely to result in that patient reaching the Maximum Program Benefit or Patient Total Program Benefit amount, by calling 844-353-9466. (See PROGRAM BENEFITS section in full Terms and Conditions.)
- ZILRETTA Co-Pay Program patients may pay as little as $0 out of pocket for each ZILRETTA injection/treatment.
- Pacira will pay the remaining eligible out-of-pocket costs on behalf of the patient until the Pacira payments have reached the Maximum Program Benefit and/or the Patient Total Program Benefit. Patients are responsible for all amounts that exceed this limit. HCPs can reach out to the ZILRETTA Co-pay Program to help you understand your patient’s eligibility by calling 1-844-353-9466. (See PROGRAM DETAILS section in full Terms and Conditions.)
- ELIGIBILITY
*Eligibility Criteria:
- Subject to Program limitations and Terms and Conditions, the ZILRETTA Co-Pay Program is open to patients (1) who have been prescribed ZILRETTA and (2) who have commercial or private insurance (including plans purchased through an employer/health insurance marketplace) that covers ZILRETTA. This Program helps eligible patients cover out-of-pocket medication costs related to ZILRETTA up to Program limits.
- The ZILRETTA Co-Pay Program does not cover any other costs related to office visits or the administration of ZILRETTA. There is no patient income requirement to participate in this Program.
- This Program is not valid for patients whose prescription for ZILRETTA 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 ZILRETTA or where the patient has commercial or private insurance but Pacira in its sole discretion determines that the patient is effectively uninsured because such coverage does not provide a material level of financial assistance for the cost of ZILRETTA treatment/prescription.
- The patient must have an on-label diagnosis for ZILRETTA as prescribed by a healthcare professional to be eligible for this Program.
- This Program is valid only to citizens/permanent residents of the United States, Puerto Rico, and the US territories 18 years of age or older.
- Additional Terms and Conditions of the Program: 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 any other healthcare reimbursement accounts for the amount of assistance received from the Program. This Program is not conditioned on any past, present, or future purchase, including additional treatments. This Program is not insurance.
- ZILRETTA is dispensed pursuant to Program rules and federal and state laws. Pacira reserves the right to rescind, revoke, amend, or terminate the Program at any time and for any reason, without notice.
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PROGRAM BENEFITS
- The ZILRETTA Co-Pay Program may modify the benefit amount, unilaterally determined by Pacira in its sole discretion, to satisfy the out-of-pocket cost-sharing requirement.
- The patient or his/her legal representative or HCP must be enrolled in the ZILRETTA Co-Pay Program to be eligible for Program benefits. Health plans and Pharmacy Benefit Managers are prohibited from enrolling or assisting in the enrollment of patients in the ZILRETTA Co-Pay Program.
- 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 Veterans Affairs programs), the patient will no longer be able to use the ZILRETTA Co-Pay Program, and the patient’s HCP must contact the ZILRETTA Co-Pay Program at 1-844-353-9466 (Monday through Friday, from 8:00 am to 8:00 pm ET) to stop the patient’s participation in this Program.
- Patients may not seek reimbursement for the value received from the ZILRETTA Co-Pay Program from any third-party payers, including a flexible spending account or healthcare savings account.
- Patient’s participation in this Program means that he/she is ensuring compliance with any required disclosure of his/her insurance carrier or Pharmacy Benefit Manager regarding HCP’s and Patient’s participation in the ZILRETTA Co-Pay Program. Patient is responsible for reporting receipt of co-pay assistance to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled, as may be required. Restrictions may apply. Offer of the Program is subject to change or discontinuation without notice.
- This Program is not health insurance and does not cover or provide support for supplies, procedures, or any physician-related services, visits, or associated payments such as deductibles, premiums, or other amounts not explicitly identified as pharmacy co-payments.
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PROGRAM DETAILS
For all eligible patients, the ZILRETTA Co-Pay Program offers:
- A Program benefit that covers the patient’s eligible out-of-pocket medication costs for ZILRETTA (co-pay or co-insurance, deductible) on behalf of the patient, up to a Maximum Program Benefit determined by the Program per calendar year. The ZILRETTA Co-Pay Program does not cover any other costs related to office visits or the administration of ZILRETTA.
- ZILRETTA Co-Pay Program patients may pay as little as $0 out of pocket for each ZILRETTA treatment.
- Pacira will pay the remaining eligible out-of-pocket prescription costs on behalf of the patient until Pacira’s payments of such costs have reached the Maximum Program Benefit and/or the Patient Total Program Benefit.
- Maximum Program Benefit, Patient Total Program Benefit; Benefits May Change, End, or Vary Without Notice: The Program provides up to a $1,000 Maximum Program Benefit of assistance to reduce a patient’s out-of-pocket medication costs that Pacira will provide per patient for each calendar year, which must be applied to the ZILRETTA patient’s out-of-pocket costs (co-pay or co-insurance, deductible, and annual out-of-pocket maximum).
- Patient Total Program Benefit amounts are unilaterally determined by Pacira at 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 Pacira, to ensure that all Program funds are used for the benefit of the patient. Each patient is responsible for costs above the Patient Total Program Benefit amounts. HCPs can reach out to the ZILRETTA Co-Pay Program for assistance to understand whether their patient’s particular insurance coverage is likely to result in reaching the Maximum Program Benefit or Patient Total Program Benefit amount by calling 1-844-353-9466.
- The Patient, or his/her legal representative, or HCP must enroll the patient in the ZILRETTA Co-Pay Program. Patient will be automatically re-enrolled in subsequent years after the initial enrollment period ends as long as the Patient still meets Program eligibility requirements.
- Participating HCPs are responsible for updating the ZILRETTA Co-Pay Program with changes to their Patient’s insurance, including, but not limited to, initiation of insurance provided by the government and the addition of any coverage terms that do not apply ZILRETTA Co-Pay Program benefits to reduce a patient’s out-of-pocket costs, such as accumulator adjustment benefit design or a co-pay maximization program. Participating HCPs are responsible for providing the ZILRETTA Co-Pay Program with accurate information necessary to determine Program eligibility.
- Patients may use the co-pay benefit every time they are treated with ZILRETTA, up to the $1,000 Maximum Program Benefit or Patient Total Program Benefits reset each calendar year.
- By using this offer, patients certify that they meet the eligibility criteria and will comply with these Terms and Conditions.
- Patients may continue in the Program if they continue to meet all of the Program’s eligibility requirements during participation in the Program. HCPs can enroll their patients into the ZILRETTA Co-Pay Program through the FlexForward HCP Portal or by fax: 1-800-862-2905.
