i. eligibility
*Eligibility Criteria: Subject to program limitations and terms and conditions, the Enbrel® Copay Card is open to patients who have a prescription for Enbrel and who have commercial insurance or private, including plans available through state and federal health care exchanges. this program helps eligible patients cover enbrel-related out-of-pocket expenses, up to program limits. There are no income requirements to participate in this program.
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This offer is not valid for patients whose enbrel prescription is paid for in whole or in part by medicare, medicaid or any other federal or state program. not valid for patients paying cash or where prohibited by law. A patient is considered to be paying cash when the patient does not have insurance coverage for Enbrel or when the patient has commercial or private insurance but Amgen, in its sole discretion, determines that the patient is not effectively insured because such coverage does not provide a material level of financial assistance for the cost of an enbrel prescription.
ii. program benefits
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the enbrel® copay card does not cover out-of-pocket expenses for any patient whose coverage option selected in their commercial insurance plan does not apply enbrel copay card payments toward the copay, deductible, or coinsurance for enbrel patients with these plan limitations are not eligible for the enbrel copay card, but may be eligible for other need-based assistance provided by amgen. these programs are often called accumulator adjustment programs. If you think your business insurance plan may have such limitations, please contact enbrel support® at 1-888-436-2735.
The enbrel copay card may also provide a reduced benefit amount, determined unilaterally by amgen in its sole discretion, to satisfy the out-of-pocket cost-sharing requirement for any patient whose plan or plan agent (including, but not limited to, other, limited to, a pharmacy benefit manager (pbm) requires enrollment in the enbrel copay card as a condition of the plan or pbm waiving some or all of an applicable patient out-of-pocket cost-sharing amount. these programs are often called copay maximization programs. if you think your commercial insurance plan may have such limitations, please contact enbrel support® at 1-888-436-2735. health plans, specialty pharmacies, and pharmacy benefit managers (individually and collectively , “plan administrators”) are prohibited from enrolling patients on the enbrel copay card. plan administrators are prohibited from assisting patients with enrollment on the enbrel copay card. the patient, or their legal representative, you must personally enroll in the enbrel copay to be eligible for program benefits.
If at any time a patient begins receiving prescription drug coverage under any state or government program (including, but not limited to, medicare, medicaid, tricare, department of defense, or veterans affairs programs), the patient will no longer be able to use this card and you must contact enbrel support® at 1-888-436-2735 (Monday-Friday, 8am-8pm ET) to stop your participation in this program .
Patients may not request reimbursement of enbrel copay card value received from third-party payers, including a flexible spending account or healthcare savings account. Participating in this program means that you ensure that you comply with any required disclosures regarding your participation in the enbrel copay card from your insurance company or pharmacy benefit manager. restrictions may apply. offer subject to change or discontinuation without notice.this is not health insurance.
iii. program details
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For all eligible patients, the enbrel® copay card offers:
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a program benefit that covers eligible patient out-of-pocket costs for prescription drugs for enbrel (copayment, deductible, or coinsurance) on behalf of the patient, up to a program benefit maximum determined by the program per calendar year.
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enbrel patients pay $5 out-of-pocket for the first fill and each refill, and amgen will pay the remaining eligible out-of-pocket costs for prescription drugs (up to the patient’s total) on the patient’s behalf. benefit of the program described below. enbrel patients are responsible for all amounts in excess of this limit).
maximum benefit of the program, total benefit of the program for the patient, benefits may change, end or vary without notice: the program provides up to a maximum benefit of the program assistance to reduce a patient’s out-of-pocket cost per prescription that amgen will provide per patient per calendar year, which must be applied to the enbrel® patient’s out-of-pocket costs (copayment, deductible or coinsurance). total patient program benefit amounts are unilaterally determined by amgen in its sole discretion and will not exceed the maximum program benefit. the total program benefit to the patient may be less than the maximum program benefit, depending on the terms of the patient’s prescription drug plan, and may vary between individual patients covered by different plans, based on factors determined solely by amgen, to ensure that all program funds are used for the benefit of the patient. each patient is responsible for costs in excess of the patient’s total program benefit amounts. ask your enbrel support® representative to help you understand if your particular insurance coverage is likely to lead you to reach the maximum program benefit or full program benefit amount as a patient by calling 1-888-436- 2735 and selecting option 1. participating patients are solely responsible for updating amgen with changes to their prescription health insurance, including, but not limited to, the initiation of government-provided insurance, the addition of any coverage terms that do not apply to enbrel copay card benefits to reduce a patient’s outflow. out-of-pocket costs, such as accumulator adjustment benefit design or a copay maximization program. Participating patients are responsible for providing amgen with accurate information necessary to determine program eligibility. When accepting Amgen payments made on behalf of Participating Patients, PBMs and Participating Plans are also responsible for providing Amgen with accurate patient eligibility information.
Patients can use the card each time they fill their enbrel prescription. benefits reset each calendar year. re-enrollment in the program is required at regular intervals. patients may participate in the program as long as the patient re-enrolls as required by amgen and continues to meet all program eligibility requirements while participating in the program. patients can enroll/re-enroll by calling 1-888-436-2735 and selecting option 1 or by visiting enbrel.com/financial-support.
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