SAPHNELO PATIENT SUPPORT

Many factors determine how much you will pay for SAPHNELO. You could pay as little as $0. The SAPHNELO Co-pay Savings Program is for commercially insured patients to cover patient out-of-pocket costs for SAPHNELO and its administration, up to $16,500 per calendar year. The out-of-pocket costs covered by the program can include the cost of the product itself and the cost of product administration (program maximum of $150 per infusion administration or injection training). Copay assistance for product administration services like drug infusion and injection education is not available to patients who are residents of Massachusetts or Rhode Island.

If you need help paying for SAPHNELO, AstraZeneca may be able to help. You can get more information on SAPHNELO affordability programs by calling 1-844-ASK-A360 (1-844-275-2360).

ELIGIBILITY:

Patients may be eligible for this offer with the following criteria:

• Insured by Commercial insurance with a valid prescription for SAPHNELO^® (anifrolumab-fnia) Intravenous infusion 300 mg OR SAPHNELO^® (anifrolumab-fnia) subcutaneous injection, 120 mg AND
• Are a resident of the United States or Puerto Rico AND
• Are not enrolled in a government funded program

Patients who are enrolled in a state or federally funded prescription insurance program are not eligible for this offer. This includes patients who are enrolled in Medicare Part B, Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DoD) programs or TriCare, and patients who are Medicare eligible and enrolled in an employer-sponsored group waiver health plan or government-subsidized prescription drug benefit program for retirees. Patients who are enrolled in a state or federally funded prescription program may not use this program even if they elect to be processed as uninsured (cash-paying). This offer is not insurance.

TERMS OF USE:

Eligible commercially insured patients with a valid prescription for SAPHNELO who enroll in this program may pay as little as $0 per administration of SAPHNELO dependent upon patient’s prescription coverage of SAPHNELO.

SAPHNELO Savings Program—If SAPHNELO is covered by the health plan:

• Up to $16,500 per calendar year in assistance for out-of-pocket expenses
• The out-of-pocket costs covered by the program can include the cost of the product itself and the cost of product administration (program maximum of $150 per infusion administration or injection training).*^,†
• Other restrictions may apply. Patient must be enrolled in the program before use. If you have any questions regarding the offer, please call 1-866-SAPHNELO (1-833-360-4357).
• Offer is invalid for claims or transactions more than 365 days from the date of service.

Other restrictions apply. Patient is responsible for applicable taxes, if any. Non-transferable, limited to one per person, cannot be combined with any other offer. Void where prohibited by law, taxed, or restricted. Patients, pharmacists, and prescribers cannot seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this offer. AstraZeneca reserves the right to rescind, revoke, or amend this offer, eligibility, and terms of use at any time without notice. This offer is not conditioned on any past, present, or future purchase, including refills. Offer must be presented along with a valid prescription for SAPHNELO at the time of purchase. Program covers the cost of the drug, infusion administration,*^,† injection training, and does not cover the costs for office visits or any other associated costs.

If you meet the Copay Savings program eligibility criteria but SAPHNELO is not covered by your health plan, you may qualify for the Denied Patient Savings Program.

If you are not approved to receive SAPHNELO by your insurance plan and an appeal has been denied, the Denied Patient Savings Program may cover the cost of SAPHNELO for up to 24 months* when you meet other eligibility requirements. This program is only administered by approved Specialty Pharmacies.

Denied Patient Savings Program Eligibility:
Patient must meet all savings program eligibility criteria in addition to the following criteria:

• A Prior Authorization denial and Prior Authorization appeal denial by your health plan are required
• SAPHNELO must be prescribed for on-label use

TERMS OF USE:
Denied Patient Savings Program—If SAPHNELO is NOT covered by the health plan:

• Prescription fills for up to 24 months from the date of the initial prescription
• This program is only administered by approved specialty pharmacies
• Program support includes periodic Benefits Investigation to identify potential changes in patient coverage. If a change in coverage is identified, the prescriber will be contacted to initiate a new Prior Authorization for the patient. If the Prior Authorization is approved, the patient will transition to coverage via their insurance benefits
• Patients denied coverage for SAPHNELO subcutaneous and currently receiving approved SAPHNELO intravenous therapy are not eligible for Denied Patient Savings Program

BY USING THIS PROGRAM, YOU AND YOUR PHARMACIST AND/OR PHYSICIAN UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS AND TERMS OF USE.

You may report side effects related to AstraZeneca products .