•Eligible commercially insured patients may pay as little as $0 per infusion
•Maximum benefit of $20,000 per year
•The Program covers only the cost of VILTEPSO and not the cost of any infusion services or healthcare provider visits, which are the sole responsibility of the patient
•Patients will be automatically reenrolled every 12 months as long as they continue to meet the eligibility requirements for participation in the Program
•An EOB from patient's private, commercial health insurance must be submitted within 365 days of the date of service on the EOB for patient to receive a copay assistance benefit
•No EOB may be submitted more than 90 days after the expiration date of the Copay Assistance Program, and the date of service on the EOB must be prior to the program expiration date
•The EOB must reflect patient's outofpocket cost for VILTEPSO and submission of the claim by HCP for the cost of the medication
•Eligible patients may be automatically enrolled once NS Support receives their completed Patient Start Form
•HCP should fax completed Start Form to 8882120482, or mail to NS Support Program, PO Box 29203, Phoenix, AZ 850389203
•Call 8336778778, Monday Friday, 8am8pm ET for assistance or additional information