Eligibility Criteria Terms and Conditions

• With this Glatiramer Acetate Copay Assistance Program, eligible patients may pay as little as $0 for each monthly fill of VIATRIS' Glatiramer Acetate Injection 20mg/mL and/or 40mg/mL, while this program remains in effect. Subject to all other Terms and Conditions, this copay assistance program may be used to reduce the amount of an eligible patient's out-of-pocket costs for VIATRIS' Glatiramer Acetate Injection 20mg/mL and/or 40mg/mL up to the full amount of the patient's out-of-pocket cost per prescription, which may be up to a 90-day supply. Restrictions, including monthly maximums and aggregate annual maximums, may apply while this copay assistance program remains in effect (such maximum amounts include dispenses of both VIATRIS' Glatiramer Acetate Injection 20mg/mL and 40mg/mL). Whether a patient is eligible to receive any applicable maximum amount is determined by the type of commercial insurance plan coverage the eligible patient has, and savings may vary among individual patients covered by different plans. No other purchase is necessary. Valid prescription is required. VIATRIS reserves the right to amend or end this copay assistance program at any time without notice.

• Eligibility Requirements: This copay assistance can be redeemed only by patients or patient guardians who are 18 years of age or older and who are residents of the U.S. or Puerto Rico. Patients must have commercial prescription drug insurance. This copay assistance program is not valid for uninsured patients (but may be used by commercially insured patients without coverage for VIATRIS' Glatiramer Acetate Injection 20mg/mL and/or 40mg/mL) and patients who are covered in whole or in part by any state or federally funded healthcare program, including, but not limited to, any state pharmaceutical assistance program, Medicare (Part D or otherwise), Medicaid, Medigap, VA or DOD, or TRICARE (regardless of whether VIATRIS' Glatiramer Acetate Injection 20mg/mL and/or 40mg/mL is covered by such government program); not valid if the patient is Medicare eligible and enrolled in an employer-sponsored health plan or prescription benefit program for retirees; and not valid if the patient's insurance plan is paying the entire cost of this prescription. This copay assistance program is void outside the U.S. or Puerto Rico or in any state or jurisdiction where prohibited by law, taxed or restricted, and may not be available in all states.
• This copay assistance program is not health insurance. The copay assistance program is not transferable, and the amount of the savings cannot exceed the patient's out-of-pocket costs. Cannot be combined with any other rebate/coupon, cash discount card, free trial, or similar offer for the specified prescription. This copay assistance is not redeemable for cash. This copay assistance is not valid for product dispensed by a 340B covered entity that purchased the product at discounted pricing under the 340B drug pricing program. This copay assistance is not valid if the patient's commercial health insurance plan or pharmacy benefit manager uses a copay adjustment program (often termed "maximizer" or "accumulator" program) that restricts any form of copay assistance from being counted toward the patient's cost-sharing limits.
• NOTICE: Data related to your use of this copay assistance program may be collected, analyzed and shared with VIATRIS for market research and other purposes related to assessing its copay assistance programs. Data shared with VIATRIS will be aggregated and de-identified, meaning it will be combined with data related to other copay assistance program redemptions and will not identify you.
• The value of this copay assistance is exclusively for the benefit of patients and is intended to be credited towards patient out-of-pocket obligations and maximums, including applicable copayments, coinsurance, and deductibles. Use of this copay assistance program must be consistent with the terms of any drug benefit provided by a commercial health insurer, health plan or private third-party payer. Patients must have not submitted and will not submit a claim for reimbursement under any federal, state or other governmental programs for this prescription. Patients are responsible for reporting the receipt of copay assistance to any commercial insurer, health plan, or third-party payer who pays for or reimburses any part of the prescription filled, as may be required. Patients should not use this copay assistance program if their health plan prohibits use of manufacturer copay assistance programs. Patients must withdraw from this copay assistance program should they begin to receive prescription benefits from any government funded program by calling 1-800-742-1616.
• By utilizing this copay assistance program, you hereby accept and agree to abide by these Terms and Conditions. Any individual or entity who enrolls or assists in the enrollment of a patient in the copay assistance program represents that the patient meets the eligibility criteria and other requirements described herein. Health plans, pharmacy benefit managers, and vendors or agents of any of the foregoing, are prohibited from enrolling or assisting in the enrollment of patients in this copay assistance program. Further, you agree that you currently meet the eligibility criteria and other requirements described herein every time you use this copay assistance program.
• Patients with questions about this copay assistance program, including eligibility, should call the Glatiramer Acetate Copay Assistance Program at 1-800-742-1616.