•* For patients with commercial insurance without coverage for Omvoh:
•Program savings for claims not covered under the medical and/or pharmacy portion of medical insurance are limited up to 3 infusions over total lifetime of the Program and up to 14 injection fills for each calendar year, subject to a combined (injection and infusion) maximum monthly savings and a separate annual maximum savings
•To receive Program savings for the $0 Program, HCP must submit a prior authorization (PA) request for Omvoh to patient's insurance provider before initiating treatment with Omvoh and provide the results of the PA demonstrating the insurance provider has denied coverage
•Patient must have commercial insurance without coverage for Omvoh and a prescription consistent with FDAapproved product labeling to pay as little as $0 for each infusion up to a maximum of 3 infusions and be enrolled in the Program on or before the date of service
•*For injections (insured/not covered patients):
•To receive Program savings for the $0 Program, HCP must submit a prior authorization (PA) request for Omvoh to patient's insurance provider prior to 1st fill, an appeal prior to 5th fill, and a PA prior to the 13th fill and provide the results of each demonstrating the insurance provider has denied coverage