ILUMYA SUPPORT PATIENT ACCESS PROGRAMS AND SERVICES TERMS & CONDITIONS

ILUMYA™ EARLY ACCESS PROGRAM TERMS AND CONDITIONS

Co-Pay Program

Eligible commercially insured patients 18 years or older may pay as little as $5/dose for an ILUMYA™ prescription, subject to a $16,000 maximum annual program benefit. After the program maximum, patient will be responsible for the difference. This offer is valid only for patients who meet the program eligibility requirements, have commercial insurance that covers ILUMYA™, and who have a valid prescription. One digital card per patient, not transferable, and cannot be combined with any other offer.

By accepting this offer, you agree that if you are required to do so under the terms of your insurance coverage for this prescription or are otherwise required to do so by law, you should notify your insurance carrier of your redemption of this Co-pay Card. This offer is not valid with any other program, discount, incentive, or similar offer involving ILUMYA™. It is prohibited for any person to sell, purchase, or trade; or to offer to sell, purchase or trade; or to counterfeit this Co-pay Card.

Early Access Program

Eligible commercially insured patients ages 18 years and older who meet program eligibility requirements and have commercial insurance are automatically enrolled in the Early Access Program without the need for an initial prior authorization (PA) and can receive ILUMYA™ free of charge for up to 2 years while appealing their denied coverage. ILUMYA SUPPORT™ will work with the patients’ provider to submit a medical and/or pharmacy PA to the patient’s insurance plan before the patient’s third dose. Patient continuation in the Early Access Program is contingent on provider submission of a medical and/or pharmacy PA before a patient’s third dose of ILUMYA™. Failure to submit a medical and/or pharmacy PA prior to the patient’s third dose, will result in the patient no longer being able to participate in the Early Access Program and no longer receiving ILUMYA™ at no cost. Patient continuation in the Early Access Program is contingent on provider submission of a medical and/or pharmacy appeal before a patient’s fourth dose of ILUMYA™. Failure to submit a medical and/or pharmacy appeal prior to the patient’s fourth dose, will result in the patient no longer being able to participate in the Early Access Program and no longer receiving ILUMYA™ at no cost. Patients may receive ILUMYA™ without charge for up to 2 years or until they obtain coverage. ILUMYA SUPPORT™ will work with the patient’s provider to submit Pas, appeals and other required information. Eligibility for the Early Access Program is validated through continuous coverage checks and may change if the patient no longer meets the current program eligibility requirements.

Co-Pay and Early Access Program

These offers for Co-pay Card and Early Access Program expire in 12 months and 24 months, respectively, based on program initiation date. These offers may be terminated, rescinded, revoked, or amended by Sun Pharmaceutical Industries, Inc., at any time, without notice. These offers are void where prohibited or restricted by law. If you live in Massachusetts or California, the Co-pay Card expires on the earlier of December 31, 2020, or date an AB-rated generic equivalent is available. These offers are not valid under Medicare, Medicaid, VA, DOD, TRICARE, or any other federal or state program, for cash-paying patients, where the product is not covered by patient’s commercial insurance, or where a plan reimburses patient for the entire cost of prescription drug. These offers are not health insurance and are only valid for patients in the United States, Guam, Virgin Islands, or Puerto Rico residents only.

The Early Access Program provides ILUMYA™ at no charge to patients for up to 2 years or until they receive insurance coverage approval, whichever occurs earlier. Offer subject to change or discontinuance without notice. This is not health insurance and program does not guarantee insurance coverage.

Before you activate your Co-pay Card or participate in the Early Access Program, it is important that you understand that you will be asked to provide personal information that may include your name, address, phone number, email address, and information related to your prescription medication insurance and treatment. This information is necessary to permit SUN Pharma, the maker of ILUMYA™, and companies that work with SUN Pharma, including our affiliates and our service providers, to fulfill your request to enroll in the ILUMYA SUPPORT™ Program. We may also use the information you give us to learn more about the people who use ILUMYA™ and to improve the information we provide to people who are being treated with ILUMYA™. SUN Pharma will not share your information with anyone else except as required by law.

By using the ILUMYA™ Co-pay Card or participating in the Early Access Program, or both, you attest that you meet the eligibility criteria and will comply with the Terms and Conditions.

If you have questions regarding eligibility or benefits, or you wish to discontinue participation, call the ILUMYA SUPPORT™ Program at 855‑4ILUMYA (855‑445‑8692), Monday through Friday, 8 AM to 8 PM ET.