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Co-pay Card Program Terms and Conditions

The Kyowa Kirin Cares co-pay assistance program for NOURIANZ (the “Program”) helps commercially insured individuals who are permanent residents of the United States (including the US territories) and who are prescribed NOURIANZ for a use approved by the Food and Drug Administration (FDA) pay for their eligible out-of-pocket costs for the drug. Under the Program, eligible patients pay the first $20 of their applicable co-payment or cost-sharing for a 30-day supply of NOURIANZ, the first $40 of their applicable co-payment or cost-sharing for a 60-day supply of NOURIANZ, or the first $60 of their applicable co-payment or cost-sharing for 90-day supply of NOURIANZ and the Program pays the remainder of their co-payment or cost-sharing obligation for NOURIANZ up to $5000 per calendar year, i.e., January 1 through December 31. Each eligible patient is responsible for the first $20 of their out-of-pocket costs for a 30-day supply of NOURIANZ, the first $40 of their applicable co-payment or cost-sharing for a 60-day supply of NOURIANZ, or the first $60 of their applicable co-payment or cost-sharing for a 90-day supply of NOURIANZ per month and any amounts above the monthly and yearly maximums set forth above. Eligible patients must obtain a new Program card annually to continue enrollment in the Program.

The Program is limited to patients 18 years of age or older. The Program is NOT insurance.

Eligible individuals must have commercial insurance coverage for NOURIANZ. Uninsured and cash-paying individuals are NOT eligible for the Program, nor are individuals with commercial insurance coverage that does not provide coverage for NOURIANZ. Individuals with coverage for NOURIANZ, in whole or in part, under any state or federally funded healthcare program, including but not limited to, Medicare, Medicare Advantage Plans, Medicare Part D (including Qualified Retiree Prescription Drug Plans), Medicaid, Medigap, VA, DoD, TRICARE, and the Puerto Rico Government Health Insurance Plan, are NOT eligible for the Program. Patients who move from commercial to state or federally funded insurance will no longer be eligible for the Program.

Void if copied, transferred, purchased, altered, or traded, and where prohibited and restricted by law.

All coverage requirements of the eligible patient that are mandated by the insurance company must be satisfied for the Program to take effect. When submitting claims under the Program, patients are certifying that they understand the Program rules, regulations, and terms and conditions, and will comply with the Program terms as set forth herein. Additionally, you are certifying that a claim has not been submitted under a state or federally funded healthcare program, including but not limited to, Medicare, Medicare Advantage Plans, Medicare Part D (including Qualified Retiree Prescription Drug Plans), Medicaid, Medigap, VA, DoD, TRICARE, and the Puerto Rico Government Health Insurance Plan.

Kyowa Kirin reserves the right to make eligibility determinations, to set Program benefit maximums, to monitor participation, and to change, rescind, revoke, or discontinue the Program at any time without notice. Limit one Program enrollment per individual. If you have any questions regarding this Program, your eligibility, or benefits, or if you wish to discontinue your participation, call 833-KK-Cares Program Monday through Friday, 8 AM to 8 PM, Eastern Standard Time (ET).