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.