^†Myfembree® Copay Assistance Program Terms, Conditions, and Eligibility Criteria

• To be eligible for the Myfembree Copay Assistance Program (“Copay Program”), patients must have commercial prescription insurance, have a valid prescription for an FDA-approved indication of Myfembree, be 18 years or older, and be a resident of the U.S., Puerto Rico, or U.S. Territories.
• The Copay Program is not valid for patients enrolled in any state or federal government program, including, but not limited to, Medicaid, Medicare, Medigap, Department of Defense (DoD), Veterans Affairs (VA), TRICARE, Puerto Rico Government Insurance, or any state pharmaceutical assistance program. Patients may not use this offer if they are Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. Offer is not valid for cash-paying patients.
• The benefit under the Copay Program is offered to, and intended for the sole benefit of, eligible patients and may not be transferred to or utilized for the benefit of third parties, including, without limitation, third party payers, pharmacy benefit managers, or the agents of either.
• Copay Card cannot be combined with any other external savings, free trial or similar offer for the specified prescription (including any program offered by a third party payer or pharmacy benefit manager, or an agent of either, that adjusts patient cost-sharing obligations, through arrangements that may be referred to as “accumulator” or “maximizer” programs)
• Third party payers, pharmacy benefit managers, or the agents of either, are prohibited from assisting patients with enrolling in the Copay Program.
• With this Copay Program, eligible patients may pay as little as $5 per prescription for up to an 84-day supply of Myfembree. This Copay Program is subject to a calendar year maximum savings of $5,000. After the calendar year maximum savings is reached, patient will be responsible for the remaining out-of-pocket costs for Myfembree.
• This card is valid for up to 12 prescription fills for a 28-day supply or 4 prescription fills for an 84-day supply.
• The Copay Program is good only in the U.S., Puerto Rico, or U.S. Territories at participating retail pharmacies. This Copay Program is void where prohibited by law and on the date an AB rated generic equivalent for Myfembree becomes available.
• This offer is not health insurance.
• This offer has no cash value and cannot be combined with any other coupon, free trial, discount, prescription savings card, or other similar offer for the specified prescription.
• This offer is not conditioned on any past or future purchase, including refills.
• This card is not transferable. The selling, purchasing, trading, or counterfeiting of this card is prohibited by law.
• Patient and participating pharmacists agree not to seek reimbursement from any insurer or third party for all, or any part of the benefit received by the patient through this Copay Program.
• Patient and participating pharmacists agree to report the receipt of Copay Program benefits to any insurer or other third party who pays for or reimburses any part of the prescription filled using the Copay Program, as may be required by such insurer or third party.
• Sumitomo Pharma America reserves the right to revoke, rescind, or amend this offer without notice.
• By redeeming this card, you acknowledge that you are an eligible patient and that you understand and agree to comply with the terms and conditions of this offer.

Pharmacy Instructions:

Pharmacist Instructions for a patient with an eligible third-party payer: When you redeem this card, you certify that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other government health insurance programs for this prescription.

• Process a Coordination of Benefits (COB/split bill) claim using the patient’s prescription insurance for the PRIMARY claim. Submit a SECONDARY claim to PDMI using BIN: 610020 (No PCN required). Offer not valid for discount cards, uninsured/cash patients.
• Valid Other Coverage Code required. For any questions regarding processing, please call the Help Desk at 1-833-693-3627. Program managed by Mercalis on behalf of Sumitomo Pharma America, Inc.