Vivimusta CONNECT

Directions: For assistance, please complete this form and fax it to 1.855.854.3931. You can also call 1.844.472.2628, Monday-Friday 8 am–6 pm ET, to speak with a Vivimusta CONNECT^® Case Manager.

COMMERCIAL CO-PAY ASSISTANCE - ENROLLMENT FORM

REQUIRED FIELDS ARE MARKED IN BOLD. PLEASE NOTE THAT MISSING INFORMATION WILL DELAY OUR ABILITY TO ASSIST YOU IN ACCESSING SUPPORT

PATIENT DEMOGRAPHIC INFORMATION

PATIENT INSURANCE

Primary Medical Insurance Information

Secondary Medical Insurance Information

PATIENT APPLICATION REQUIREMENTS: (This application MUST contain the following information to be processed)

Explanation of Benefits (EOB)–Ensure the document clearly states the Vivimusta product name and/or NDC and the patient’s out of pocket expense.

PHYSICIAN INFORMATION

PATIENT AUTHORIZATION AND CONSENT

Patient Authorization: By signing below, I authorize my healthcare providers and their staff, including any specialty pharmacies that dispense my medication, and my health insurer(s)/health plan(s) (collectively, my “healthcare team”), to disclose to Azurity Pharmaceuticals, Inc., its affiliates, vendors, and agents (collectively, “Azurity Pharmaceuticals, Inc.”), information related to me and my medical condition and treatment, including but not limited to prescriptions, and my health insurance coverage and claims (collectively, “My Information”), for the purposes of enrolling me in Vivimusta CONNECT^® and providing me with certain services and information. Specifically, I authorize such disclosures to Azurity Pharmaceuticals, Inc. to use and share my Information with my healthcare team to: (1) establish my eligibility for insurance to cover Vivimusta^® (2) facilitate my obtaining Vivimusta^® (3) contact me regarding my enrollment and participation in the Program and my use or potential use of Vivimusta^® and (4) provide me with information about Vivimusta^® and other products, including promotional and educational communications. I also have reviewed and agree with the below Terms and Conditions for the Vivimusta CONNECT^® Co-Pay Assistance Program. I understand that the services provided by these programs may be revised, changed, or terminated at any time. I certify that I am at least 18 years old.

VIVIMUSTA CONNECT^® CO-PAY PROGRAM FOR VIVIMUSTA^® TERMS AND CONDITIONS

By using the Vivimusta CONNECT^® Co-pay Program you certify that you meet the eligibility criteria and will comply with the Terms and Conditions described below.

Co-pay Assistance is not valid for prescriptions that are eligible to be reimbursed, in whole or in part, by Medicaid, Medicare, or other federal or state healthcare programs (including any state prescription drug assistance programs and the Government Health Insurance Plan available in Puerto Rico [formerly known as “La Reforma De Salud”]).
The patient must be ≥18 years of age to be eligible for this program
Co-pay assistance is not valid for prescriptions that are eligible to be reimbursed by private insurance plans or other health or pharmacy benefit programs that reimburse you for the entire cost of your prescription drugs.
Each patient is limited to one active co-pay assistance offer at a time during this offer period and the Co-pay assistance offer is not transferable.
Co-pay assistance cannot be combined with any other rebate or coupon, free trial, or similar offer for the specified prescription.
Co-pay assistance is not health insurance.
This offer is good only in the United States and Puerto Rico as allowed by law.
Azurity reserves the right to rescind, revoke, or amend co-pay assistance without notice.
Offer valid until the end of the current calendar year

Azurity Pharmaceuticals, Inc., reserves the right to rescind, revoke, or amend this program without notice. This offer is not conditioned on any past, present, or future purchase, including refills. The program terms and offer will expire at the end of each calendar year.

This authorization may be signed electronically. By typing your name at the bottom of this page, you agree that you are signing this document. You understand that your electronic signature is legally binding, just as if you signed a paper document, and you acknowledge that you have read and understand the Patient Authorization.