Full Terms & Conditions
ADVANCING Patient Support Copay Assistance Program
Eligibility and Restrictions
In order to qualify for Copay Assistance, patients must enroll in the ADVANCING Patient Support Program and meet the following eligibility criteria:
- Must be 18 years of age or older.
- Must live in and receive treatment in the United States or U.S. Territories.
- Be in receipt of a valid prescription for ZYNLONTA™ for an FDA-approved indication.
- Have Private or Commercial Health Insurance with coverage for ZYNLONTA™. The patient must be enrolled in and seek reimbursement from a commercial health plan—such as a plan through an employer or a commercial plan that is purchased in the healthcare exchange marketplace. The Copay Assistance Program is not valid for patients covered, in whole or in part, under a federal or state healthcare program such as Medicaid (including Medicaid patients enrolled in a qualified health plan purchased through a health insurance exchange/marketplace established by a state government or the federal government), Medicare, a Medicare Part D or Medicare Advantage plan (regardless of whether a specific prescription is covered), TRICARE, CHAMPUS, Puerto Rico Government Health Insurance Plan (“Healthcare Reform”), or any other state or federal medical or pharmaceutical benefit program or pharmaceutical assistance program (collectively, “Government Programs”).
- The Copay Assistance Program is not valid for uninsured patients.
- Eligible patients may pay $0 of copay per dose of ZYNLONTA™. The benefit available under the Copay Assistance Program is limited to the amount that the patient's private health insurance company indicates on the Explanation of Benefits (EOB). The patient is obligated to pay for ZYNLONTA™ up to an annual maximum. The maximum Copay Assistance Program benefit per patient, per calendar year (January 1 through December 31), is $25,000. Enrolled patients are responsible for all copays and any other balances not covered by the Copay Assistance Program.
- An Explanation of Benefits (EOB) from your/the patient's private health insurance must be submitted within 180 days of the date of administration for the patient to receive any applicable copay assistance benefit; provided, however, that no EOB may be submitted more than 365 days after the expiration date of Copay Assistance Program. The EOB must reflect the patient's out-of-pocket cost for ZYNLONTA™ and submission of the claim by the patient's provider for the cost of ZYNLONTA™.
- The benefit available under the Copay Assistance Program is valid for the patient's out-of-pocket cost for ZYNLONTA™ only. It is not valid for any other out-of-pocket costs (for example, office visit charges or medication administration charges) even if such costs are associated with the administration of ZYNLONTA™. A claim for ZYNLONTA™ must be submitted by the provider to the patient's private health insurance separately from claims for any other services and products.
- Patient and provider agree not to seek reimbursement for all, or any part of, the benefit received by the patient through the Copay Assistance Program. Patient and provider are responsible for reporting receipt of Copay Assistance Program benefits to any insurer, health plan, or other third party who pays for or reimburses any part of the medication cost paid for by the Copay Assistance Program, as may be required.
- By participating in this Copay Assistance Program, the patient authorizes his or her provider to submit the EOB received from his or her private insurance company to the Copay Assistance Program and to receive on patient’s behalf, if applicable, any benefit for which the patient is eligible under the Copay Assistance Program. The provider agrees to apply any amounts received from the Copay Assistance Program toward the satisfaction of patient’s obligation for the cost of ZYNLONTA™ only. Patient will be responsible for any amount owed to his or her provider per dose of ZYNLONTA™ that is not covered by the Copay Assistance Program. If patient has already paid provider for his or her share of the cost of ZYNLONTA™ for which he or she later receives a benefit through the Copay Assistance Program, patient will seek the amount, less the amount patient owes per dose, back from his or her provider.
- The Copay Assistance Program is not insurance. If your insurance status changes, you must notify the ADVANCING Patient Support Program immediately.
- The Copay Assistance Program is void where prohibited by law, taxed, or restricted. The Copay Assistance Program offer is not transferable and is limited to one offer per person. No substitutions are permitted. Not valid if reproduced. This offer cannot be redeemed for cash.
- The Copay Assistance Program benefit cannot be combined with any other Copay Assistance Program, free trial, discount, prescription savings card, or other offer. Cash Discount Cards and other non-insurance plans are not valid as primary insurance under this offer.
- If acquiring ZYNLONTA™ from a Specialty Pharmacy (to be later administered in a physician office or outpatient institution), additional documentation may be required.
- This program is managed by TrialCard on behalf of ADC Therapeutics. ADC Therapeutics reserves the right to rescind, revoke, or amend the Copay Assistance Program at any time without notice.
- No other purchase is necessary.
- The Copay Assistance Program is not contingent on any past or commercial sale of any ZYNLONTA™.
- These Terms and Conditions are valid for ZYNLONTA™ administered between April 23, 2021, and December 31, 2021.
By using this offer, you are certifying that you meet the eligibility criteria and will comply with the terms and conditions described herein and will not seek reimbursement for any benefit received through this card. ADC Therapeutic’s Eligibility and Restrictions, and Offer Details may change from time to time, and for the most recent version, please visit ADVANCINGPatientSupport.com/copay-terms-conditions. Reconfirmation of information may be requested periodically to ensure accuracy of data and compliance with terms.
When you apply this offer, you are certifying that you have not submitted a claim for reimbursement under any Government Program for this prescription, or where prohibited by law. Participation in this program must comply with all applicable laws and regulations as a pharmacy provider. By participating in this program, you are certifying that you will comply with the eligibility criteria, and terms and conditions described herein. You also certify that you will not seek reimbursement for any benefit received through this offer.