INSUPPORT® Copay Assistance Program

Terms and Conditions

To receive benefits under the INSUPPORT Copay Assistance Program, you must be determined as eligible and be enrolled in the Copay Assistance Program.

Eligibility Requirements:

• You must have private health insurance that provides coverage for some portion of the cost of SUBLOCADE under a medical or pharmacy benefit plan. The Copay Assistance Program is not valid for uninsured individuals.
• Individuals with government insurance are not eligible for the Copay Assistance Program, including, but not limited to Medicare, Medicaid, Medigap, VA, DOD, TriCare, CHAMPVA or any other federally or state-funded government-assisted program.
• You are at least 18 years of age.
• The Copay Assistance Program is available to individuals only for "on-label" use.
• You are a resident of the United States or U.S. territories, based on your address.
• You are a resident of a state where copay assistance is not prohibited.
• Your private insurance has not prohibited coupons/copay assistance for SUBLOCADE.
• You have been prescribed SUBLOCADE by your treatment provider.
• The INSUPPORT Copay Assistance Program is not insurance.

Program Enrollment:

• You must request eligibility determination and enrollment for the Copay Assistance Program via the INSUPPORT Patient Enrollment Form or www.insupport.com/savings.
• Enrollment information that is modified or does not contain the information required will not be accepted by INSUPPORT for evaluation of Program eligibility.
• Copay member information may be provided to you via mail, email address, or mobile phone number for patients who opt-in to text communications, provided during the enrollment/re-enrollment processes. You may opt-out of these notifications at any time by contacting INSUPPORT.
• Patient Authorization is required for INSUPPORT to enroll an eligible individual in the INSUPPORT Copay Assistance Program. Patient Authorization is:
  
  • Valid for five years from the date of signature.
  • Required to be provided each calendar year to continue receiving benefits, assuming all eligibility criteria continues to be met.
• The eligibility period for the Copay Assistance Program is based on calendar year (January-December).
  
  • Yearly re-enrollment is no longer required for the Copay Assistance Program.
  • If you enrolled in copay assistance, you can continue using the same copay card the following year of enrollment.
  • If you misplaced your copay card information, please contact INSUPPORT at (844) 467-7778 to obtain your copay card information over the phone.

Program Benefit and Conditions:

• You may pay as little as $0 per injection of SUBLOCADE throughout the eligibility period.
• Following your initial enrollment in the Program, and each subsequent calendar year you remain on SUBLOCADE and continue to meet the Program eligibility criteria, you will receive the following medication copay assistance:
  
  • You will receive an expanded benefit amount for the first two injections in the calendar year. The expanded benefit amount is up to $2,016.52 for SUBLOCADE.
  • Following the first two injections of SUBLOCADE in the same calendar year, you will receive a maximum copay assistance amount of $800 per injection for the remainder of the calendar year.
  • If your financial responsibility for the medication is greater than the maximum benefit per injection, you will be responsible for any remaining costs not covered by the copay assistance benefit dollars.
  • Expanded benefit resets at beginning of each calendar year.
• The Program benefit may be applied for maximum of 14 injections per calendar year and requires that there must be a minimum of 23 days between dates of service. The maximum possible annual benefit is $13,633.04.
• The benefit amounts stated above may change in your welcome letter, where the amounts provided in the Copay Assistance Program Terms and Conditions shall control over the amounts described above. Indivior Inc. reserves the right to rescind, revoke, or amend the INSUPPORT Copay Assistance Program at any time without notice.
• If SUBLOCADE is covered under your medical benefit plan:
  
  • An Explanation of Benefits (EOB) from your private health insurer must be submitted within 180 days of the date of the EOB for you to receive copay assistance benefit. The EOB must reflect your out-of-pocket cost for SUBLOCADE and submission of the claim by your provider for the cost of SUBLOCADE.
• The benefit available under the Copay Assistance Program is valid for your out-of-pocket cost for SUBLOCADE 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 SUBLOCADE. Claims for SUBLOCADE must be submitted by the provider to your private health insurance separately from other services and products.
• Copay claims will be processed, and benefits applied, in the order in which they are received.
• You agree not to seek reimbursement (in full or in part) from any insurer or payor, including a flexible spending or healthcare savings account, for any or all of the benefit you have received through the Copay Assistance Program.
• You agree to notify INSUPPORT immediately if your health insurance status changes, or if you become entitled to, or enroll in a government health insurance program/payer.
• The Copay Assistance Program benefit is non-transferable, limited to one person, and cannot be combined with any other Copay Assistance Program, free trial, discount, prescription savings card, or other offer. Offer has no cash value.
• Aggregated and non-identifiable information from individuals participating in the INSUPPORT Copay Assistance Program may be collected, analyzed, summarized, and shared with Indivior Inc., and its affiliates for market research, statistical, and other purposes related to assessing the Copay Assistance Program.

Patient Authorization for Use and Disclosure of Health and Personal Information

I authorize (1) My treatment provider (including his/her staff, any affiliated group practices, and/or any provider I am referred to by my current treatment provider), (2) the health insurer(s) listed on my enrollment form, and (3) the specialty pharmacy to which my SUBLOCADE prescription is sent for fulfillment to use and to disclose to Indivior Inc. (including any of its affiliates), which sponsors the INSUPPORT program (collectively, "Indivior"); IQVIA Inc., McKesson Corporation and any of its affiliates, including RxCrossroads by McKesson, SourceHOV L.L.C., NDC Health Corporation d/b/a/ RelayHealth, Capgemini America, Inc., Symphony Health Solutions, Corporation (including its affiliate Source Healthcare Analytics, L.L.C.), all of which play a role in the INSUPPORT program; AmerisourceBergen Corporation (including its affiliate Xcenda L.L.C.), and my Alternate Patient Contact(s) (if named) (collectively "Recipients") my personal and medical information (my "Information"), including any information about me on this enrollment form and/or about my medical treatment with SUBLOCADE, for purposes of facilitating my enrollment in and participation in the INSUPPORT program. I further authorize the Recipients to share my Information among themselves, so that one or more of them can: a) administer and/or provide INSUPPORT program services or information related to my enrollment; b) conduct an insurance benefit verification and communicate my health insurance company's requirements for access to treatment with SUBLOCADE; c) coordinate and route information among Recipients to help in the coordination of my treatment with SUBLOCADE; d) provide me with educational or support services by mail, e-mail, and/or telephone, which may include sending me product and/or treatment information e) invite me to participate in optional surveys about my treatment, and/or; f) provide me with program information about, determine if I am eligible for, and help with my enrollment and continued participation in, the INSUPPORT® Copay Assistance Program for SUBLOCADE. I understand that my specialty pharmacy may receive payment from Indivior Inc. in exchange for providing my Information per this authorization.

Providing this authorization is my choice. I understand that I do not need to provide this authorization in order to obtain treatment, insurance, or insurance benefits; I am required to provide authorization only if I wish to participate in the INSUPPORT program. Any communication conveying my mental health or drug treatment Information in reliance on this authorization must include a notice that such Information may not be shared further. I understand that other Information shared in reliance on this authorization might, once shared, no longer be subject to federal privacy law and could be shared further.

I can revoke my authorization at any time by calling 1-844-INSPPRT (844-467-7778) or by mailing a signed written statement of my revocation to INSUPPORT at IQVIA Inc. ATTN: Processing Claims Department, 77 Corporate Drive, Bridgewater, NJ 08807. I understand that such a revocation will not apply to uses or disclosures made before INSUPPORT receives my statement of revocation. If I do not revoke the authorization, it will expire five (5) years from the date I sign below, or upon such earlier date as may be mandated by state law. I have the right to receive a copy of this authorization after I sign it.

By accepting benefits under the INSUPPORT® Copay Assistance Program for SUBLOCADE, I certify that I have read, understand, and agree to Terms and Conditions of the Program and that I meet the Program's eligibility requirements

I certify that I have read, understand, and agree to the Patient Authorization