Patient Assistance
Options

^aBy enrolling in the VYLOY Copay Assistance Program ("Program"), the patient acknowledges that they currently meet the eligibility criteria and will comply with the following terms and conditions: The Program is for eligible patients with commercial prescription insurance for VYLOY® (zolbetuximab-clzb) and is good for use only with a valid prescription for VYLOY. The Program has an annual maximum copay assistance limit of $25,000 per calendar year. After the annual maximum on copay assistance is reached, patient will be responsible for the remaining monthly out-of-pocket costs for VYLOY. The Program is not valid for patients whose prescription claims are reimbursed, in whole or in part, by any state or federal government program, including, but not limited to, Medicaid, Medicare, Medigap, Department of Defense (DoD), Veterans Affairs (VA), TRICARE, Puerto Rico Government Insurance, or any state patient or pharmaceutical assistance program. Patients who move from commercial insurance to federal or state prescription health insurance will no longer be eligible, and agree to notify the Program of any such change. This offer is not valid for cash paying patients. Patients agree not to seek reimbursement from any health insurance or third party for all or any part of the benefit received by the patient through the Program. This offer is not conditioned on any past, present, or future purchase of VYLOY. This offer is not transferable, has no cash value, and cannot be combined with any other offer, free trial, prescription savings card, or discount (including any program offered by a third-party payer or pharmacy benefit manager, or an agent of either, that adjusts patient cost-sharing obligations, through arrangements that may be referred to as "accumulator" or "maximizer" programs). The full value of the Program benefits is intended to pass entirely to the eligible patient. The benefit available under this Program is valid only for the patient's out-of-pocket medication costs for VYLOY. The benefit is not valid for any other out-of-pocket costs such as medication administration charges or other healthcare provider services. No other individual or entity (including, without limitation, third party payers, pharmacy benefit managers, or the agents of either) is entitled to receive any benefit, discount, or other amount in connection with this Program. This offer is not health insurance and is only valid for patients in the 50 United States, Washington DC, and Puerto Rico. This Program is void where prohibited by law. No membership fees. Certain rules and restrictions apply. Astellas reserves the right to revoke, rescind, or amend this offer without notice for any reason (including to ensure that the offer is utilized solely for the patient's benefit).

^bSubject to eligibility. Program terms and conditions apply. Void where prohibited by law.