Soliqua 100/33

Soliqua Savings Program: This savings program is not insurance. You agree to report the receipt of offer benefits to any insurer or other third party who pays for or reimburses any part of the prescription filled using the offer, if required by such insurer or third party. This offer is not valid for prescriptions covered by or submitted for reimbursement, in whole or in part, under Medicare, Medicaid, VA, DOD, TRICARE, similar federal or state programs, including any state pharmaceutical programs. If you have an Affordable Care (Health Care Exchange) plan, you may still be qualified to receive and use this offer. Please note: the Federal Employees Health Benefits (FEHB) Program is not a federal or state government health care program for purposes of the program. Void where prohibited by law. For the duration of the program, eligible commercially insured payer-approved patients pay as little as $35 per 30-day supply with a max savings of $365 per pack, up to two packs, per 30-day supply. Eligible commercially insured payer-rejected and cash-paying patients may pay as little as $99 per pack, up to two packs, per 30-day supply. Savings may vary depending on patients’ out-of-pocket costs. The program applies to the cost of medication. There are other relevant costs associated with overall treatment. By redeeming this offer, you are certifying that: (1) you are not a beneficiary of any government funded programs as noted above; (2) should you begin receiving prescription benefits from any government funded program, you will withdraw from the program; and (3) you acknowledge and understand that adherence to the terms and conditions of this offer, as noted above, is necessary to ensure compliance with laws pertaining to Federal Healthcare Programs. Sanofi reserves the right to rescind, revoke, terminate, or amend this offer, eligibility, and terms of use at any time without notice.

Commercially insured patients using this card with their insurance: By using this savings card for co-pay assistance, you agree that this program is intended to help you, the patient, afford your medication. Some health insurers or pharmacy benefit managers (or their agents) have established programs (sometimes called “accumulator adjustment” or “co-pay maximizer” programs) that change patients’ drug out-of-pocket cost obligations based on whether drug manufacturer support for these costs is available and/or exclude drug manufacturer assistance for patient out-of-pocket drug costs from counting towards patient deductibles or out-of-pocket cost limitations. If your health plan implements either an accumulator adjustment or co-pay maximizer program, you will not be eligible for, and agree not to use, co-pay assistance under this card because these programs are inconsistent with our agreed intent that co-pay assistance from Sanofi is solely intended to benefit patients. However, you remain eligible to continue using this card outside of your insurance coverage. By using this savings card for co-pay assistance, you also agree that you are personally responsible for paying any out-of-pocket expenses required after the maximum amount of the savings card is applied. Any out-of-pocket costs remaining after the application of the savings card may not be paid by your health plan, pharmacy benefit programs, or any other program. Since you may not know if you are subject to a co-pay maximizer program, Sanofi will monitor Savings program utilization data and reserves the right to discontinue co-pay assistance at any time without notice. If your health plan removes your medication from being subject to a co-pay maximizer, you will regain eligibility for co-pay assistance up to the maximum annual benefit.

For questions regarding your eligibility or benefits, call the Soliqua Savings Program at (833) 950-1304.

(9:00 am-7:00 pm EST, Monday-Friday)