Patient Instructions 

• Patient may be asked to submit documentation (e.g., federal tax returns; IRS forms such as W-2, 1099, 4506T; Social Security statement/checks/benefit letter; pension or disability benefit statement/letter; unemployment compensation statement; pay stubs) to validate levels of income
• pharma& will review all submitted documentation, including the pharma& Patient Assistance Program eligibility form and all substantiating information, prior to approving a patient for eligibility under the pharma& Patient Assistance Program
• Both the patient and prescriber must sign and date all submitted documentation to attest to the accuracy of the information
• Uninsured patients, commercially insured patients, and federal healthcare program beneficiaries who qualify for the pharma& Patient Assistance Program are enrolled for the entire calendar year. However, pharma& reserves the right to reassess eligibility for uninsured patients and patients with commercial insurance during the calendar year
• The pharma& Patient Assistance Program is not insurance
• Provision of free product under this program is not contingent upon future purchase or prescribing of RUBRACA
• No patient, pharmacy, payer, or other third party may be billed for the free product provided through the pharma& Patient Assistance Program.
• Patients and providers agree not to submit any claims for reimbursement for all or any part of the free product provided through the pharma& Patient Assistance Program. If the HCP or pharmacy receives any payments for products provided under this program, they agree to return such payments to the applicable payer or patient
• Patient, pharmacist, and prescriber agree to not sell, purchase, trade, or offer to sell, purchase, or trade any free product received through the pharma& Patient Assistance Program
• Patient cannot apply the value of the free product received through the pharma& Patient Assistance Program toward any insurance benefit out-of-pocket spending calculations
• pharma& retains the right to make the final decision regarding any pharma& Patient Assistance Program product request. All product requests are subject to review at pharma&’s sole discretion, and all decisions by pharma& are final
• pharma& requires that you re-apply every year
• pharma& reserves the right to modify or revoke this program at any time without notice