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.