ENBREL Support® Enrollment
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SUMMARY OF TERMS AND CONDITIONS
It is important that every patient read and understand the full Enbrel® Co-Pay Card Terms and Conditions. The following summary is not a substitute for reviewing the Terms and Conditions in their entirety.
As further described below, in general:
- •The Enbrel Co-Pay Card is open to patients with commercial insurance, regardless of financial need. The program is not valid for patients whose Enbrel prescription is paid for in whole or in part by Medicare, Medicaid, or any other federal or state programs. It is not valid for cash paying patients or where prohibited by law. (See ELIGIBILITY section below.)
- •The Enbrel Co-Pay Card may help lower your Enbrel monthly out-of-pocket costs. Monthly out-of-pocket costs include co-payment, co-insurance, and deductible out-of-pocket costs. The Enbrel Co-Pay Card provides support up to the Maximum Program Benefit or Patient Total Program Benefit. If a patient’s commercial insurance plan imposes different or additional requirements on patients who receive Enbrel Co-Pay Card benefits, Amgen has the right to reduce or eliminate those benefits. Whether you are eligible to receive the Maximum Program Benefit or Patient Total Program Benefit is determined by the type of plan coverage you have. Please ask your ENBREL Support® Representative to help you understand eligibility for the Enbrel Co-Pay Card, whether your particular insurance coverage is likely to result in your reaching the Maximum Program Benefit or your Patient Total Program Benefit amount by calling 1-888-436-2735 and selecting option 1. (See PROGRAM BENEFITS section below.)
- •Enbrel patients pay $5 out-of-pocket at the first fill and at every refill and Amgen will pay the remaining eligible out-of-pocket costs on behalf of the patient until the Amgen payments have reached either the Maximum Program Benefit and/or the Patient Total Program Benefit. Patients are responsible for all amounts that exceed this limit. (See PROGRAM DETAILS section below.)
I. ELIGIBILITY
*Eligibility Criteria: Subject to program limitations and terms and conditions, the Enbrel® Co-Pay Card is open to patients who have an Enbrel prescription and who have commercial or private insurance, including plans available through state and federal healthcare exchanges. This program helps eligible patients cover out-of-pocket costs related to Enbrel, up to program limits. There is no income requirement to participate in this program.
This offer is not valid for patients whose Enbrel prescription is paid for in whole or in part by Medicare, Medicaid, or any other federal or state programs. It is not valid for cash-paying patients or where prohibited by law. A patient is considered cash-paying where the patient has no insurance coverage for Enbrel or where the patient has commercial or private insurance but Amgen in its sole discretion determines the patient is effectively uninsured because such coverage does not provide a material level of financial assistance for the cost of an Enbrel prescription.
II. PROGRAM BENEFITS
The Enbrel® Co-Pay Card does not cover out-of-pocket costs for any patient whose selected coverage option under their commercial insurance plan does not apply Enbrel Co-Pay Card payments to satisfy the patient’s co-payment, deductible, or co-insurance for Enbrel. Patients with these plan limitations are not eligible for the Enbrel Co-Pay Card but may be eligible for other needs-based assistance provided by Amgen. These programs are often referred to as accumulator adjustment programs. If you believe your commercial insurance plan may have such limitations, please contact ENBREL Support® at 1-888-436-2735.
The Enbrel Co-Pay Card also may provide a reduced benefit amount, unilaterally determined by Amgen in its sole discretion, to satisfy the out-of-pocket cost sharing requirement for any patient whose plan or plan agent (including, but not limited to, a Pharmacy Benefit Manager (PBM)) requires enrollment in the Enbrel Co-Pay Card as a condition of the plan or PBM waiving some or all of an otherwise applicable patient out-of-pocket cost sharing amount. These programs are often referred to as co-pay maximizer programs. If you believe your commercial insurance plan may have such limitations, please contact ENBREL Support® at 1-888-436-2735. Health plans, Specialty pharmacies, and Pharmacy Benefit Managers (individually and collectively “Plan Administrators”) are prohibited from enrolling patients in the Enbrel Co-Pay Card. Plan Administrators are prohibited from assisting patients with enrollment in the Enbrel Co-Pay Card. The patient, or his/her legal representative, must personally enroll in the Enbrel Co-Pay in order to be eligible for program benefits.
If at any time a patient begins receiving prescription drug coverage under any state or government program (including but not limited to Medicare, Medicaid, TRICARE, Department of Defense, or Veteran Affairs programs), the patient will no longer be able to use this card and you must contact ENBREL Support® at 1-888-436-2735 (Monday through Friday, from 8AM to 11PM (ET)) to stop your participation in this program.
Patients may not seek reimbursement for the value received from the Enbrel Co-Pay Card from any third-party payers, including a flexible spending account or healthcare savings account. Participating in this program means that you are ensuring you comply with any required disclosure regarding your participation in the Enbrel Co-Pay Card of your insurance carrier or pharmacy benefit manager. Restrictions may apply. Offer subject to change or discontinuation without notice. This is not health insurance.
III. PROGRAM DETAILS
For all eligible patients the Enbrel® Co-Pay Card offers:
- •A program benefit that covers the patient’s eligible out-of-pocket prescription costs for Enbrel (co-pay, deductible, or co-insurance) on behalf of the patient, up to a Maximum Program Benefit determined by the program per calendar year.
- • Enbrel patients pay $5 out-of-pocket at the first fill and at every refill, and Amgen will pay on behalf of the patient the remaining eligible out-of-pocket prescription costs (up to the Patient Total Program Benefit described below. Enbrel patients are responsible for all amounts that exceed this limit.).
Maximum Program Benefit, Patient Total Program Benefit, Benefits May Change, End or Vary without notice: The program provides up to a Maximum Program Benefit of assistance to reduce a patient’s out-of-pocket prescription costs that Amgen will provide per patient for each calendar year, which must be applied to the Enbrel® patient’s out-of-pocket costs (co-pay, deductible, or co-insurance). Patient Total Program Benefit amounts are unilaterally determined by Amgen in its sole discretion and will not exceed the Maximum Program Benefit. The Patient Total Program Benefit may be less than the Maximum Program Benefit, depending on the terms of a patient’s prescription drug plan, and may vary among individual patients covered by different plans, based on factors determined solely by Amgen, to ensure all programs funds are used for the benefit of the patient. Each patient is responsible for costs above the Patient Total Program Benefit amounts. Please ask your ENBREL Support® Representative to help you understand whether your particular insurance coverage is likely to result in your reaching the Maximum Program Benefit or your Patient Total Program Benefit amount by calling 1-888-436-2735 and selecting option 1. Participating patients are solely responsible for updating Amgen with changes to their prescription health insurance including, but not limited to, initiation of insurance provided by the government, the addition of any coverage terms that do not apply Enbrel Co-Pay Card benefits to reduce a patient’s out-of-pocket costs, such as accumulator adjustment benefit design or a co-pay maximization program. Participating patients are responsible for providing Amgen with accurate information necessary to determine program eligibility. By accepting payments from Amgen made on behalf of participating patients, participating PBMs and Plans likewise are responsible for providing Amgen with accurate information regarding patient eligibility.
Patients may use the card every time they fill their Enbrel prescription. Benefits reset each calendar year. Re-enrollment in the program is required at regular intervals. Patients may participate in the program as long as patient re-enrolls as required by Amgen and continues to meet all of the program’s eligibility requirements during participation in the program. Patients can enroll/re-enroll by calling 1-888-436-2735 and selecting option 1 or by going to Enbrel.com/financial-support.