Terms and Conditions for the Co-pay Assistance Program for ZINPLAVA™ (bezlotoxumab) Injection 25 mg/mL:

• To receive benefits under the Co-pay Assistance Program for ZINPLAVA™ (bezlotoxumab) Injection 25mg/mL (“Program Product”) the patient must enroll in the Co-pay Assistance Program and be accepted as eligible.
• Patient must be prescribed the Program Product for an FDA-approved indication.
• Patient must be 18 years of age or older and must have private health insurance that provides coverage for the cost of the Program Product under a medical benefit plan.
• The Co-pay Assistance Program is not valid for patients covered under Medicaid (including Medicaid patients enrolled in a qualified health plan purchased through a health insurance exchange [marketplace] established by a state government or the federal government), Medicare, a Medicare Part D or Medicare Advantage plan (regardless of whether a specific prescription is covered), TRICARE, CHAMPUS, Puerto Rico Government Health Insurance Plan (“Healthcare Reform”), or any other state or federal medical or pharmaceutical benefit program or pharmaceutical assistance program (collectively, “Government Programs”). The Co-pay Assistance Program is not valid for uninsured patients.
• Absent a change in Massachusetts law, effective January 1, 2020, the coupon will no longer be valid for residents of Massachusetts.
• Patient must have an out-of-pocket cost for the Program Product and be administered the Program Product prior to the expiration date of the Co-pay Assistance Program. The benefit available under the Co-pay Assistance Program is valid for the patient’s out-of-pocket cost for the Program Product only. It is not valid for any other out-of-pocket costs (for example, office visits charges or medication administration charges) even if such costs are associated with the administration of the Program Product. Claim for Program Product must be submitted by health care provider to patient’s private health insurance separately from other services and products.
• Patient must pay the first $100 of co-pay on the administration of Program Product. The benefit available under the Co-pay Assistance Program is limited to the amount the patient’s private health insurance company indicates on the Explanation of Benefits (EOB) that the patient is obligated to pay for the Program Product, less $100, up to a maximum benefit of $3,700 for one (1) vial of Program Product. If two (2) vials of Program Product are required to be administered in one infusion, the patient is obligated to pay for the Program Product, less $100, up to a maximum benefit of $7,500. Co-pay assistance is available on a subsequent administration of Program Product, provided patient remains enrolled in the Program and remains eligible, provided however, that co-pay assistance is not available on any administration of Program Product that occurs less than 100 days after any previous administration of Program Product for which co-pay assistance was sought. Subsequent administration is subject to all Terms and Conditions.
• An EOB from patient’s private health insurance must be submitted, along with all other required documentation in support of the Co-Pay Assistance Program claim, within 180 days of the date of the EOB for patient to receive co-pay assistance benefit; provided, however, that no EOB or required documentation may be submitted more than 180 days after the expiration date of Co-pay Assistance Program. The EOB must reflect the patient’s out-of-pocket cost for the Program Product and submission of the claim by the patient’s health care provider for the cost of the Program Product.
• Patient and health care provider agree not to seek reimbursement for all or any part of the benefit received by the patient through the Co-pay Assistance Program. Patient and health care provider are responsible for reporting receipt of Co-pay Assistance Program benefits to any insurer, health plan, or other third party who pays for or reimburses any part of the medication cost paid for by the Co-pay Assistance Program, as may be required.
• Patient must be a resident of the United States or the Commonwealth of Puerto Rico. Product must originate and be administered to patient in the United States or the Commonwealth of Puerto Rico.
• The Program may apply to patient out-of-pocket costs incurred for Program Product within 90 days prior to the date patient is enrolled in the Co-pay Assistance Program.
• All information applicable to the Co-pay Assistance Program requested on this form must be provided, and all certifications must be signed. Forms that are modified or do not contain all the necessary information will not be eligible for benefits under the Co-pay Assistance Program.
• No other purchase is necessary.
• The Co-pay Assistance Program is not insurance.
• The Co-pay Assistance Program form may not be sold, purchased, traded, or counterfeited. Void if reproduced.
• The Co-pay Assistance Program is void where prohibited by law, taxed, or restricted. The Co-pay Assistance Program is not transferable. No substitutions are permitted.
• The Co-pay Assistance Program benefit cannot be combined with any other Co-pay Assistance Program, free trial, discount, prescription savings card, or other offer. Benefits are not available through this Co-pay Assistance Program for product purchased by patient at a pharmacy, even if later administered in a health care provider office or outpatient institution.
• Merck reserves the right to rescind, revoke, or amend the Co-pay Assistance Program at any time without notice.
• Data related to patient’s receipt of Co-pay Assistance Program benefits may be collected, analyzed, and shared with Merck, for market research and other purposes related to assessing Co-pay Assistance Programs. Data shared with Merck will be aggregated and de-identified, meaning it will be combined with data related to other Co-pay Assistance Program redemptions and will not identify patient.
• These Terms and Conditions are valid for Program Product administered between January 1, 2020, and December 31, 2020.
• Expiration Date: 12/31/2020.