I am enrolling in DUPIXENT MyWay® and authorize Regeneron Pharmaceuticals, Inc., Sanofi US, and their agents (together the "Alliance") to provide me services which may include medication and adherence communications and support, medication dispensing support, coverage and financial assistance support, disease and medication education, injection training and other support services.
I agree to my enrollment in the DUPIXENT MyWay® Copay Card program (“Program”) if confirmed as eligible, understand that copay card information will be sent to my designated specialty pharmacy along with my prescription, and any assistance with my applicable cost-sharing or co-payment for DUPIXENT (dupilumab) will be made in accordance with the Program terms and conditions.
The maximum annual patient benefit under the DUPIXENT MyWay® Copay Card Program is $13,000. Copay amounts after applying copay assistance may depend on the patient’s insurance plan and may vary. The Program is intended to help patients access DUPIXENT. Patients may have insurance plans that attempt to dilute the impact of the assistance available under the Program. In those situations, the Program may change its terms in order to enable patients to realize the full benefits of the assistance available under the Program.
I authorize the Alliance to contact me by mail, telephone, or email, with information about DUPIXENT MyWay®, disease state and products, promotions, services and research studies, and to ask my opinion about such information and topics, including market research and disease-related surveys (together, the “Communications”).
I further authorize the Alliance to de-identify my health information and use it in performing research, education, business analytics, marketing studies or for other commercial purposes. I understand that members of the Alliance may share identifiable health information with one another in order to de-identify it for these purposes and as needed to perform individual support services or to send the Communications. I understand and agree that the Alliance may use my health information for these purposes and may share my health information with my doctors, specialty pharmacies, and insurers.
I understand that I do not have to enroll in DUPIXENT MyWay® or receive the Communications, and that I can still receive DUPIXENT injection, as prescribed by my physician. I may opt out of receiving Communications, individual support services, including the DUPIXENT MyWay® Copay Card, or opt out of DUPIXENT MyWay® entirely at any time by notifying a representative by telephone at 1-800-633-1610 or by sending a letter to Sanofi US Customer Service P.O. Box 5925 Mailstop 55A-220A Bridgewater, NJ 08807.
I also understand that DUPIXENT MyWay® reserves the right to rescind, revoke, terminate, or amend this offer, eligibility, and terms and conditions at any time without notice. Commercially insured patients with questions or concerns about deductible, copay, or coinsurance amounts or the ability to obtain DUPIXENT can contact the Copay Card Program helpline at 1-855-520-3765.