Copay Assistance Program Terms & Conditions

Eligibility Requirements

The ValorumPRO Copay Assistance Program is available only to eligible patients with commercial insurance coverage for the prescribed Valorum product.

Patients are not eligible if they are enrolled in or have coverage through Medicare, Medicaid, TRICARE, Veterans Affairs (VA), or any other federal- or state-funded healthcare program.

Patients must meet all Program eligibility requirements at the time assistance is provided.

Benefit

For eligible patients receiving ARMLUPEG:

• Maximum benefit of $5,500 per treatment
• Maximum benefit of $15,000 per calendar year

Program benefits may be applied only to eligible patient out-of-pocket costs associated with the prescribed product. Benefit amounts are subject to applicable Program limits and available funding.

Patient Authorization and Attestation

By enrolling in and participating in the Program, the patient or authorized representative:

• Authorizes ValorumPRO and its service providers to verify Program eligibility and administer copay assistance.
• Certifies that the patient has eligible commercial insurance coverage.
• Certifies that the patient is not enrolled in Medicare, Medicaid, TRICARE, Veterans Affairs, or any other government-funded healthcare program.
• Agrees to notify ValorumPRO promptly of any change in insurance coverage or other information that may affect Program eligibility.
• Certifies that all information provided in connection with Program enrollment is complete and accurate to the best of their knowledge.

Claims Submission and Payment

Program payments are issued on behalf of the eligible patient to the healthcare practice identified on the applicable prescription or enrollment documentation.

Each payment is associated with a specific eligible claim and date of service and may not be applied to another patient, claim, product, or date of service.

To request reimbursement, the healthcare provider or authorized representative must submit appropriate documentation, including an Explanation of Benefits (EOB) or Remittance Advice (RA), through the ValorumPRO portal or other approved submission method.

Complete claims will generally be reviewed within two (2) business days of receipt. Additional information may be requested when necessary to verify eligibility or process a claim.

Program Restrictions

Program benefits:

• Have no cash value and may not be redeemed for cash.
• May not be transferred to another patient.
• May not be combined with assistance prohibited by applicable law, payer requirements, or Program rules.
• May only be used for eligible out-of-pocket costs associated with the applicable Valorum product.
• Are subject to applicable annual and per-treatment benefit maximums.

Patients and healthcare providers are responsible for complying with any applicable insurance plan requirements and all applicable laws and regulations.

Changes in Eligibility

Patients must report any change in insurance coverage or eligibility status. Enrollment in Medicare, Medicaid, TRICARE, Veterans Affairs, or another government-funded healthcare program may result in immediate loss of eligibility for copay assistance.

ValorumPRO may verify insurance coverage and Program eligibility at enrollment and periodically during participation in the Program.

Program Administration

ValorumPRO reserves the right to modify eligibility criteria, benefit limits, Program requirements, or these Terms & Conditions, or to suspend or discontinue the Program, at any time and without prior notice, subject to applicable law.

Participation in the Program does not guarantee insurance coverage or reimbursement for the prescribed product.