Organon Co-pay Assistance Program for RENFLEXIS^® (infliximab-abda) for injection, for intravenous use 100 mg (Effective January 1, 2021)

Terms and Conditions

The Co-pay Assistance Program for RENFLEXIS consists of two sets of Terms of Conditions, one applicable to RENFLEXIS for which a claim is submitted by a patient’s health care provider (“Medical Benefit”) and the other applicable to RENFLEXIS purchased by a patient at a participating pharmacy (“Pharmacy Benefit”). Both sets of Terms and Conditions for the Co-pay Assistance Program for RENFLEXIS are set forth below.

Terms and Conditions – RENFLEXIS - (Medical Benefit):

• To receive benefits under the Co-pay Assistance Program for RENFLEXIS (“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 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.
• Subject to changes in state law, the Co-pay Assistance Program may become invalid for residents of Massachusetts prior to its expiration date.
• 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 visit 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 $5 of co-pay per 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 $5, up to an annual maximum. The maximum Co-pay Assistance Program benefit per patient, per calendar year (January 1 through December 31), is $20,000.
• An EOB from patient’s private health insurance must be submitted within 90 days of the date of the EOB for patient to receive co-pay assistance benefit; provided, however, that no EOB may be submitted more than 90 days after the expiration date of the 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, subject to annual Program maximum and the applicable Terms and Conditions based on Program Product administration date. Patient or provider may contact The Organon Access Program for more information.
• All information applicable to the Co-pay Assistance Program requested on the enrollment 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 RENFLEXIS^® (infliximab-abda) for injection, for intravenous use 100 mg purchased by patient at a pharmacy. Co-pay assistance may be available from Organon on RENFLEXIS purchased by patient at a pharmacy through separate Terms and Conditions, provided, however, that the per patient annual maximum Co-pay Assistance Program benefit on RENFLEXIS across Terms and Conditions is $20,000 per calendar year.
• Organon 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 Organon, for market research and other purposes related to assessing Co-pay Assistance Programs. Data shared with Organon 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, 2021 and December 31, 2021.
• Please read the accompanying Medication Guide for RENFLEXIS, including the information about serious infections and cancers, and discuss it with your doctor. The physician Prescribing Information also is included.
• Expiration Date: 12/31/2021.

Terms and Conditions – RENFLEXIS^® (infliximab-abda) for injection, for intravenous use 100 mg - (Pharmacy Benefit)

• To receive benefits under the Co-pay Assistance Program for RENFLEXIS (“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 have private health insurance that provides coverage for the cost of the Program Product purchased by the patient at an eligible participating pharmacy.
• 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.
• Subject to changes in state law, this coupon may become invalid for residents of Massachusetts prior to its expiration date.
• Patient must have an out-of-pocket cost for the Program Product and purchase the Program Product prior to the expiration date of the Co-pay Assistance Program. Patient must pay the first $5 of co-pay on each prescription for Program Product (regardless of quantity supplied on the prescription). The benefit available under the Co-pay Assistance Program is limited to the amount of the patient’s actual out-of-pocket cost over $5, on each prescription, up to an annual maximum. The maximum Co-pay Assistance Program benefit per patient, per calendar year (January 1 through December 31), is $20,000. 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 visit charges or medication administration charges) even if such costs are associated with the administration of the Program Product.
• The Co-pay Assistance Program coupon 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 these Terms and Conditions for RENFLEXIS for which a claim was submitted by a health care provider to a patient’s private health insurance company. Co-pay assistance may be available from Organon for RENFLEXIS for which a claim was submitted by a health care provider to a patient’s private health insurance company through separate Terms and Conditions, provided, however, that the per patient annual maximum Co-pay Assistance Program benefit for RENFLEXIS across Terms and Conditions is $20,000 per calendar year.
• Patient, pharmacist, and prescriber agree not to seek reimbursement for all or any part of the benefit received by the patient through the Co-pay Assistance Program. Patient is responsible for reporting receipt of Co-pay Assistance Program coupon 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.
• Co-pay Assistance Program coupon can be redeemed only by eligible residents of the United States or the Commonwealth of Puerto Rico at participating eligible retail or mail-order pharmacies in the United States or the Commonwealth of Puerto Rico. Product must originate in the United States or the Commonwealth of Puerto Rico.
• Co-pay Assistance Program benefits are not available for patient costs incurred prior to the date the patient is determined to be eligible under and enrolled in the Co-pay Assistance Program.
• All information applicable to the Co-pay Assistance Program requested on the enrollment 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 coupon 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.
• Organon reserves the right to rescind, revoke, or amend the Co-pay Assistance Program at any time without notice.
• Co-pay Assistance Program coupon is the property of Organon and must be turned in on request.
• Data related to patient’s receipt of Co-pay Assistance Program benefits may be collected, analyzed, and shared with Organon, for market research and other purposes related to assessing Co-pay Assistance Program programs. Data shared with Organon 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.
• Please read the accompanying Medication Guide for RENFLEXIS^® (infliximab-abda) for injection, for intravenous use 100 mg, including the information about serious infections and cancers, and discuss it with your doctor. The physician Prescribing Information also is included.
• Expiration Date: 12/31/2021.

US-SBT-11029 05/21