The Organon Co-pay Assistance Program (“Co-pay Assistance Program”) for RENFLEXIS^® (infliximab-abda) for injection, for intravenous use 100 mg, applies to claims that are submitted by a patient’s health care provider (“Medical Benefit”) and purchases by a patient at a participating pharmacy (“Pharmacy Benefit”). General Terms and Conditions apply to both the Medical Benefit and the Pharmacy Benefit. Below the General Terms and Conditions, you will find Specific Terms and Conditions for the Medical Benefit and Specific Terms and Conditions for the Pharmacy Benefit.

General Terms and Conditions

• To receive benefits under the Organon Co-pay Assistance Program (“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 (for the Medical Benefit) or when purchased by the patient at an eligible participating pharmacy (for the Pharmacy Benefit).
• 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 [also known as a 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.
• The Co-pay Assistance Program is void where prohibited by law, taxed, or restricted. Co-pay Assistance Program is not transferable. No substitutions are permitted.
• Patient must have an out-of-pocket cost for the Program Product and purchase or be administered the Program Product prior to the expiration date of the Co-pay Assistance Program. Patient must pay the first $5 of co-pay per prescription and/or administration of Program Product. 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 and/or administration, up to an annual maximum. 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 annual maximum for each eligible patient is determined by Organon in its sole discretion and may be changed at any time and for any reason. The annual maximum shall be disclosed to each patient when the patient calls into the following number: 866-847-3539. Organon will disclose the annual maximum as required by applicable law.
• Patient, pharmacist, 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 (for both Medical Benefit and Pharmacy Benefit) and health care provider (for Medical Benefit) 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. Program Product must originate and be administered to patient in the United States or the Commonwealth of Puerto Rico.
• The Co-pay Assistance Program may apply to patient out-of-pocket costs incurred for Program Product within 180 days prior to the date patient is enrolled in the Co-pay Assistance Program, subject to annual Co-pay Assistance Program maximum and the applicable Terms and Conditions based on Program Product administration date. Patient or health care 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 forms may not be sold, purchased, traded, or counterfeited, and may be void if reproduced with such intent.
• The Co-pay Assistance Program benefit cannot be combined with any other co-pay assistance programs, free trial, discount, prescription savings card, or other offer.
• 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.

Specific Terms and Conditions for the Medical Benefit:

• Claim for Program Product must be submitted by a health care provider to patient’s private health insurance separately from other services and products.
• 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.
• An EOB from patient’s private health insurance must be submitted within 180 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 180 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.
• Benefits are not available through the Medical Benefit 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 for RENFLEXIS purchased by patient at a pharmacy through the Pharmacy Benefit Co-pay Assistance Program, provided, however, that the per-patient annual maximum Co-pay Assistance Program benefit for RENFLEXIS under the General Terms and Conditions has not been exceeded.

Specific Terms and Conditions for the Pharmacy Benefit:

• The Pharmacy Benefit Co-pay Assistance Program is not available for RENFLEXIS if a claim was submitted by a health care provider to a patient’s private health insurance company as that claim would be included in the Medical Benefit Co-pay Assistance Program.
• Benefits are not available through the Pharmacy Benefit Co-pay Assistance Program for RENFLEXIS purchased by patient at a pharmacy. Co-pay assistance may be available from Organon for RENFLEXIS purchased by patient at a pharmacy through the Medical Benefit Co-pay Assistance Program, provided, however, that the per-patient annual maximum Co-pay Assistance Program benefit for RENFLEXIS under the General Terms and Conditions has not been exceeded.
• Before prescribing RENFLEXIS, please read the accompanying Prescribing Information, including the Boxed Warning. The Medication Guide also is available.

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