Getting and paying for TEZSPIRE

I. ELIGIBILITY

*Eligibility Criteria: Subject to program limitations and terms and conditions, the TEZSPIRE^® Co-Pay Card is open to patients who have been prescribed TEZSPIRE and who have commercial or private insurance that covers TEZSPIRE, including state and federal plans commonly referred to as “healthcare exchange plans.” This program helps eligible patients cover TEZSPIRE out-of-pocket medication and in-office administration costs, up to program limits. Patients who are residents of Massachusetts or Rhode Island are not eligible for injection administration support. The Co-Pay Card does not cover any other costs related to office visits. There is no income requirement to participate in this program.

This offer is not valid for patients whose TEZSPIRE prescription is paid for in whole or in part by Medicare, Medicaid, or any other federal or state healthcare program. The TEZSPIRE Co-Pay Card cannot be combined with any other savings, free trial, free goods or similar offer related to TEZSPIRE. 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 TEZSPIRE or where the patient has commercial or private insurance but Amgen and AstraZeneca in their sole discretion determine the patient is effectively uninsured because such coverage does not provide a material level of financial assistance for the cost of a TEZSPIRE prescription. This offer is only valid in the United States, Puerto Rico, and the US territories.

II. PROGRAM BENEFITS

The TEZSPIRE Co-Pay Card may modify the benefit amount, unilaterally determined by Amgen and AstraZeneca in their 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 TEZSPIRE 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 TEZSPIRE Together Co-pay Program at 1-800-818-1770. Health plans and Pharmacy Benefit Managers are prohibited from enrolling or assisting in the enrollment of patients in the TEZSPIRE Co-Pay Card. The patient, or his/her legal representative, must personally enroll in the TEZSPIRE Co-Pay Card in order to be eligible for program benefits.

If at any time a patient begins receiving coverage for medications or in-office administration costs under any federal, state, or government healthcare 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 must contact the TEZSPIRE Together Co Pay Program at 1-800-818-1770 (Monday through Friday, from 9AM to 8PM EST) to stop your participation in this program.

Patients may not seek reimbursement for the value received from the TEZSPIRE 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 TEZSPIRE 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 TEZSPIRE^® Co-Pay Card offers:

• A program benefit that covers the patient’s eligible TEZSPIRE out-of-pocket medication and in-office administration costs (may include co-pay, deductible, or co-insurance) on behalf of the patient, up to a Maximum Program Benefit or Patient Total Program Benefit determined by the program per calendar year. The Co-Pay Card does not cover any other costs related to office visits.
• TEZSPIRE patients may pay as little as $0 for each dose of TEZSPIRE medication. They may also receive up to $100 per month for out-of-pocket costs for in-office administration of TEZSPIRE (pre filled syringe only) but are responsible for all administration costs that exceed this amount. Patients who are residents of Massachusetts or Rhode Island are not eligible for injection administration support. Amgen and AstraZeneca will pay the remaining eligible TEZSPIRE out-of-pocket costs on behalf of the patient until the Amgen and AstraZeneca payments have reached either the Maximum Program Benefit or the Patient Total Program Benefit. Patients are responsible for all amounts that exceed this limit.

Program coverage through the TEZSPIRE Co-Pay Card is contingent on (1) the submission of the required Explanation of Benefits (EOB) form within 180 days of the date of approval documented on the EOB for medical benefit claims or (2) the submission of the claim within 180 days of the date of service for pharmacy benefit claims.

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 support to reduce a patient’s out-of-pocket costs that Amgen and AstraZeneca will provide per patient for each calendar year, which must be applied to the TEZSPIRE^® patient’s out-of-pocket costs (co-pay, deductible, or co-insurance and annual out-of-pocket maximum). Patient Total Program Benefit amounts are unilaterally determined by Amgen and AstraZeneca in their 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 plan, and may vary among individual patients covered by different plans, based on factors determined solely by Amgen and AstraZeneca, to ensure all program 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 TEZSPIRE Together Co pay Program 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 1-800-818-1770. Participating patients are solely responsible for updating Amgen and AstraZeneca with changes to their insurance including, but not limited to, initiation of insurance provided by the government, the addition of any coverage terms that do not apply TEZSPIRE 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 and AstraZeneca with accurate information necessary to determine program eligibility. By accepting payments from Amgen and AstraZeneca made on behalf of participating patients, participating PBMs and Plans likewise are responsible for providing Amgen and AstraZeneca with accurate information regarding patient eligibility.

Patients may use the card every time they receive a prescription fill or dose of TEZSPIRE, up to the Maximum Program Benefit or Patient Total Program Benefit. Benefits reset each calendar year. Re-enrollment in the program is required at regular intervals. Patients may continue in the program as long as patient re-enrolls as required by Amgen and AstraZeneca and continues to meet all of the program’s eligibility requirements during participation in the program. Patients can enroll/re-enroll by going to copay.TEZSPIRETogether.com or by calling 1-800-818-1770.