Scholar Rock Supports Commercial Copay Program Terms and Conditions

Under the Scholar Rock Supports Commercial Copay Program (“Copay Program”) eligible commercially insured patients who have been prescribed ISEMBYLD^™ (apitegromab-mstn) may receive assistance for out-of-pocket copays, co-insurance, or deductible requirements, subject to the terms and conditions set forth below.

• The Copay Program provides support only up to the maximum benefit available under the Copay Program. Patients are responsible for any out-of-pocket costs once the maximum program benefit is reached.
• To be eligible for the Copay Program, the following criteria must be met:
  • Patients must be two years of age or older with a valid prescription for ISEMBYLD in accordance with the FDA-approved prescribing information for ISEMBYLD.
  • Patients must have commercial (private) insurance with coverage for ISEMBYLD that does not cover the full cost of ISEMBYLD or its administration. The Copay Program covers the patients’ out-of-pocket costs for ISEMBYLD and its administration only to the extent not covered by the patient’s commercial insurance. The Copay Program is not available if the entire cost of ISEMBYLD and its administration are reimbursed by insurance.
  • Patients may not seek reimbursement from any other plan or program (e.g., Flexible Spending Account [FSA], Health Savings Account [HSA], Health Reimbursement Account [HRA]) for any out-of-pocket costs covered by the Copay Program.
  • Patients are not eligible if they have health insurance coverage through a federal or state healthcare program, such as Medicare, Medicaid, MediGap, CHAMPVA, TRICARE, Veterans Affairs, the Department of Defense, State Pharmaceutical Assistance Programs (SPAPs), or any other federal- or state-funded healthcare program. Patients who have commercial insurance and switch to insurance under a federal or state healthcare program must notify Scholar Rock Supports immediately and will no longer be eligible for the Copay Program.
  • Patients must apply in order to be enrolled in the Copay Program and must continue to meet all eligibility criteria to remain enrolled.
  • Patients with commercial insurance that provides no coverage for ISEMBYLD, that prohibits the use of copay assistance, or that reimburses the entire cost of ISEMBYLD, and its administration are not eligible for assistance through the Copay Program for ISEMBYLD.
  • Patients must live and receive ISEMBYLD in the United States or a United States territory.
  • The Copay Program is not available for patients paying cash for ISEMBYLD and its administration.
• Patients are responsible for appropriately reporting enrollment in the Copay Program as required by their commercial insurance. It is the patient’s responsibility to ensure compliance with all terms and conditions of their commercial insurance. If a patient’s commercial insurance imposes different or additional requirements on patients who receive financial assistance under the Copay Program, Scholar Rock Supports has the right to modify or eliminate financial assistance available under the Copay Program.
• The Copay Program is not health insurance or a health benefit plan. The Copay Program does not obligate the use of a specific provider.
• If a patient has enrolled in an accumulator adjustment, co-pay maximizer, or similar program that purports to help manage costs, or later learns that their commercial insurance has implemented such a program, the patient must inform Scholar Rock Supports immediately. If Scholar Rock determines that a patient’s insurer has implemented a program that adjusts patient cost-sharing obligations based on the availability of support under the Copay Program (sometimes called a “co-pay maximizer program”), unless prohibited by law, Scholar Rock may discontinue the cost-sharing assistance available under the Copay Program after providing assistance in an amount not to exceed the lesser of the Affordable Care Act (ACA) out-of-pocket maximum or current Copay Program limit. If Scholar Rock determines that a patient’s insurer has implemented a program that excludes the financial assistance provided under the Copay Program from counting towards the patient’s deductible or out-of-pocket cost limitations (sometimes called an “accumulator adjustment program”), unless prohibited by law, Scholar Rock may reduce the cost-sharing assistance available under the Copay Program.
• Patient (or their healthcare providers) must submit an Explanation of Benefits (EOB) following each infusion in order for financial assistance to be applied from the Copay Program. Claims will be processed and benefits applied against the patient’s maximum benefit amount in the order in which claims are received.
• The Copay Program does not apply where prohibited by law, taxed, or restricted. The Copay Program will not provide financial assistance for the costs of administration of ISEMBYLD for patients who are residents of or receive treatment in Massachusetts or Rhode Island.
• The Copay Program is limited to one per person. No substitutions are permitted.
• Financial assistance under the Copay Program is not transferable. The selling, purchasing, trading, or counterfeiting of financial assistance is prohibited by law. The financial assistance has no cash value and may not be used in combination with any other discount, coupon, rebate, free trial, or similar offer for the specified prescription.
• The Copay Program will be administered by a third-party program administrator on behalf of Scholar Rock Supports and Scholar Rock.
• Patient, pharmacist, and prescriber agree not to seek reimbursement for all, or any part of the benefit received by the patient through the Copay Program.
• This Copay Program is offered to, and intended for the sole benefit of, eligible patients and may not be utilized for the benefit of third parties, including, without limitation, third-party payers, pharmacy benefit managers, or the agents of either. The full value of the Copay Program benefit must be passed on to the patient. No other entity, including any administrator or applicable payor, shall receive any price concession in connection with the Copay Program.
• The Copay Program cannot be combined with any other coupon, free trial, discount, prescription savings card, or other offer (including, without limitation, any program offered by a third-party payer or pharmacy benefit manager, or an agent of either, that adjusts patient cost-sharing obligations).
• Patients are not eligible to use the Copay Program for a product if they are currently receiving free drug assistance through Scholar Rock’s patient assistance program for that product.
• No other purchase is necessary to redeem this offer.
• Acceptance of a patient into the Copay Program does not guarantee the patient’s future participation in, or eligibility for, the Copay Program.
• Scholar Rock Supports and Scholar Rock reserve the right to modify or discontinue the Copay Program with respect to any patient, or in its entirety, for any reason at any time, without notice.