Prescribe Omvoh with confidence. Your patients have access to treatment.

By enrolling in the Omvoh Savings Card Program (“Program”) and using the Omvoh Savings Card (“Card”), you attest that you meet the eligibility criteria, agree to, and will comply with the terms and conditions described below:

Eligibility:

Program savings for Omvoh infusion

For patients with commercial drug insurance with coverage for Omvoh: You must (a) have coverage for Omvoh through your commercial drug insurance but your insurance does not cover the full cost (i.e., you have a co-pay or coinsurance obligation) and (b) have a prescription for an approved use consistent with FDA-approved product labeling to pay as little as $5 for each infusion. The Program will cover your co-pay or coinsurance for Omvoh, less $5, up to the maximum monthly, annual, and lifetime limits outlined below. After the monthly and/or annual maximum savings are reached, you will be responsible for paying any remaining monthly/annual out-of-pocket costs. Card may be used for a maximum of up to 3 infusions over the lifetime of the Program. Program may provide support for infusions with a date of service that falls within 120 days prior to the date the enrollment form is received by the Program.

To receive Program savings, your healthcare provider must submit a claim for coverage to your medical insurance provider. If your medical insurance provider does not cover the full cost of the claim, your healthcare provider must then submit an Explanation of Benefits (EOB) form and a CMS 1450 or 1500 form to https://medicalclaimsportal.opushealth.com within 180 days of the infusion date of Omvoh. The submitted form must include the name of the insurer and plan and demonstrate that Omvoh was the medication administered. You understand and agree that Lilly will make a payment of your Program savings on your behalf to your healthcare provider. Participation in the Program requires a valid patient HIPAA authorization upon enrollment into the Program. Subject to Lilly USA, LLC’s (“Lilly”) right to terminate, rescind, revoke, or amend Card eligibility criteria and/or Card terms and conditions which may occur at Lilly’s sole discretion, without notice, and for any reason. Savings may continue until 06/30/2028 or for up to 30 months whichever comes first, provided you continue to meet the Program’s terms and conditions, and you first utilize the Program savings no later than 12/31/2025.

For patients with commercial drug insurance without coverage for Omvoh: You must (a) have commercial drug insurance without coverage for Omvoh, (b) have a prescription for an approved use consistent with FDA-approved product labeling, and (c) be enrolled in the Program on or before the date of the infusion to pay as little as $0 for each infusion. Card may be used for a maximum of up to 3 infusions over the lifetime of the Program. Program savings are subject to maximum monthly, annual, and lifetime limits, outlined below. After the monthly and/or annual maximum savings are reached, you will be responsible for paying any remaining monthly/annual out-of-pocket costs. To receive Program savings, your healthcare provider must submit a prior authorization (PA) request for Omvoh to your insurance provider before initiating treatment with Omvoh and provide the results of the PA demonstrating your insurance provider has denied coverage for non-administrative reasons to Lilly Support Services^™ for Omvoh. Participation in the Program requires a valid patient HIPAA authorization to remain in the Program. Subject to Lilly USA, LLC’s (“Lilly”) right to terminate, rescind, revoke, or amend Card eligibility criteria and/or Card terms and conditions which may occur at Lilly’s sole discretion, without notice, and for any reason. Savings may continue until 06/30/2028 or for up to 30 months whichever comes first, provided you continue to meet the Program’s terms and conditions, and you first utilize the Program savings no later than 12/31/2025.

Program savings for Omvoh injections

For patients with commercial drug insurance with coverage for Omvoh: You must have commercial drug insurance that covers Omvoh and a prescription consistent with FDA-approved product labeling to pay as little as $5 per month for Omvoh injections. Month is defined as 28-days and up to 1 fill. Program savings are subject to maximum monthly, annual, and lifetime limits, outlined below. Card may be used for a maximum of up to 14 prescription fills of the injection per calendar year. Participation in the Program requires a valid patient HIPAA authorization upon enrollment in the Program. Subject to Lilly USA, LLC’s (“Lilly”) right to terminate, rescind, revoke, or amend Card eligibility criteria and/or Card terms and conditions which may occur at Lilly’s sole discretion, without notice, and for any reason. Savings may continue until 06/30/2028 or for up to 30 months whichever comes first, provided you continue to meet the Program’s terms and conditions, and you first utilize the Program savings no later than 12/31/2025.

For patients with commercial drug insurance without coverage for Omvoh: You must have commercial drug insurance without coverage for Omvoh and a prescription consistent with FDA-approved product labeling to pay as little as $0 per month for Omvoh injections. Month is defined as 28 days and up to 1 fill. Program savings are subject to maximum monthly, annual, and lifetime limits, outlined below. Card may be used for a maximum of up to 14 prescription fills of the injection per calendar year. Participation in the Program requires a valid patient HIPAA authorization to remain in the Program. To receive Program savings, your healthcare provider must submit a prior authorization (PA) request for Omvoh to your insurance provider prior to your 1st fill of Omvoh and provide the results of the PA demonstrating your insurance provider has denied coverage for non-administrative reasons to Lilly Support Services™ for Omvoh. To continue receiving Program savings, your healthcare provider must submit an appeal of the denial of coverage to your insurance provider prior to your 5th fill and provide the results of the appeal demonstrating your provider has denied coverage for non-administrative reasons to Lilly Support Services™ for Omvoh. To remain eligible for the Program, a new PA, appeal, or medical exception must be submitted prior to the 13^th fill and as required by Lilly at its sole discretion. Subject to Lilly USA, LLC’s (“Lilly”) right to terminate, rescind, revoke, or amend Card eligibility criteria and/or Card terms and conditions which may occur at Lilly’s sole discretion, without notice, and for any reason. Savings may continue until 06/30/2028 or for up to 30 months whichever comes first, provided you continue to meet the Program’s terms and conditions, and you first utilize the Program benefits no later than 12/31/2025.

Monthly, annual, and lifetime maximum savings for the Program

Program savings are limited to a maximum of 30 months.

For patients with commercial drug insurance with coverage for Omvoh: Program savings for claims covered under the medical and/or pharmacy portion of your medical insurance for Omvoh are limited to up to 3 infusions over the lifetime of the Program and up to 14 injection fills per calendar year, subject to a combined (injection and infusion) maximum monthly savings of wholesale acquisition cost plus usual and customary pharmacy charges and a separate maximum annual savings of $9,200 for each calendar year. Monthly and annual maximums are set at Lilly’s absolute discretion and may be changed by Lilly with or without notice.

For patients with commercial drug insurance without coverage for Omvoh: Program savings for claims not covered under the medical and/or pharmacy portion of your medical insurance are limited to up to 3 infusions over the lifetime of the Program and up to 14 injection fills per calendar year, subject to a combined (injection and infusion) maximum monthly savings of wholesale acquisition cost plus usual and customary pharmacy charges and a separate annual maximum savings. Monthly and annual maximums are set at Lilly’s absolute discretion and may be changed by Lilly with or without notice.

Additional Program Terms and Conditions

If you have an insurance plan that is participating in an alternate funding program (“AFP”) that requires you to apply to the Omvoh Savings Card Program or otherwise pursue specialty drug prescription coverage through an alternate funding vendor as a condition of, requirement for, or prerequisite to coverage of Omvoh, you are not eligible for and are prohibited from using the Omvoh Savings Card Program. AFPs include programs where coverage, reimbursement, or patient out of pocket costs for a product in some way vary based on the availability of a manufacturer co-pay program. AFPs may modify, delay, deny, restrict, or withhold insurance benefits or coverage from patients, or exclude Lilly products from coverage contingent upon a member’s use of Omvoh Savings Card Program. You agree to inform Omvoh Savings Card Program if you are or become a member of such an alternate funding program. You are responsible for any applicable taxes, fees, and any amount that exceeds the monthly or annual maximum savings. Monthly and annual maximum savings are set at Lilly’s sole and absolute discretion and may be changed by Lilly with or without notice at any time for any reason. At its sole discretion and with or without notice, Lilly may reduce, eliminate, or otherwise modify the Card savings for any reason, including but not limited to if your commercial drug insurance plan imposes additional requirements which limits or prevents you from receiving coverage for Omvoh, only allows partial coverage for Omvoh, removes coverage for Omvoh and requires you to utilize the Card, does not provide a material level of financial assistance for the cost of Omvoh, or does not apply Card payments to satisfy your
co-payment, deductible, or coinsurance for Omvoh.

Program savings are limited to the co-pay or coinsurance costs for Omvoh only, subject to a monthly and annual maximum savings, outlined above. The Program will not cover, and shall not be applied toward, the cost of any dosing procedure, any other healthcare provider service or supply charges or other treatment costs, or any costs associated with a hospital stay. Program will only be accepted at participating pharmacies. Patients with commercial drug insurance without coverage for Omvoh must use Lilly’s designated pharmacy vendor to obtain Program savings. Card savings are not valid for: Massachusetts residents if an AB-rated generic equivalent is available; California residents if an FDA-approved therapeutic equivalent is available. You must meet the Card eligibility criteria, terms and conditions every time you use the Card. If at any time you begin receiving drug coverage under any state, federal, or government funded healthcare program, you understand that you will no longer be eligible for the Omvoh Savings Card and agree to call Lilly Support Services™ for Omvoh at
1-800-LillyRx (1-800-545-5979) to stop participation. Card activation is required. You may not seek reimbursement from your health insurance, any third party, or any health savings, flexible spending, or other healthcare reimbursement accounts, for any amount of the savings received through the Card. By utilizing the Card, you agree that if you are required to do so under the terms of your insurance coverage for this prescription or are otherwise required to do so by law, you will notify your Insurance Carrier of your redemption of the Card. Card savings cannot be combined or utilized with any other program, discount, discount card, cash discount card, coupon, incentive, or similar offer involving Omvoh. You agree that this Card savings is intended solely for the benefit of you, the patient, and that the Card benefits are nontransferable. It is prohibited for any person to sell, purchase, or trade; or to offer to sell, purchase, or trade, or to counterfeit the Card. THIS CARD IS NOT INSURANCE. Lilly has the sole right to interpret and apply Card eligibility criteria, and terms and conditions. Card eligibility, and terms and conditions may be terminated, rescinded, revoked, or amended by Lilly at any time without notice and for any reason. Lilly’s sole discretion to terminate, rescind, revoke, or amend Card eligibility and/or Card terms and conditions includes the right to terminate any individual Card if Lilly determines, in its sole discretion, that a patient does not satisfy the Card’s eligibility criteria or is using or has attempted to use the Card inconsistently with these terms and conditions. Eligibility criteria, and terms and conditions for the Omvoh Savings Card Program may change from time to time; the most current version can be found at https://www.omvoh.lilly.com/savings-support. You may be required to obtain a new Card, including if any Card terms and conditions have been terminated, rescinded, revoked, or amended by Lilly. Card void where prohibited by law. Subject to Lilly USA, LLC’s (“Lilly”) right to terminate, rescind, revoke, or amend Card eligibility criteria and/or Card terms and conditions which may occur at Lilly’s sole discretion, without notice, and for any reason, savings may continue until 06/30/2028 or for up to 30 months whichever comes first, provided you continue to meet the Program’s terms and conditions and you first utilize the Program benefits no later than 12/31/2025.

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