CAMZYOS® (mavacamten) Co-Pay Assistance Program Terms & Conditions
Eligibility Requirements
- Patients must have commercial (private) insurance, but their coverage does not cover the full cost of the prescription. Co-pay assistance is not valid where the entire cost of the prescription is reimbursed by insurance
- Patients must be 18 years of age or older
- Patients must live in the United States or United States territories
- Patients are not eligible if they have prescription insurance coverage through a state or federal healthcare program, including but not limited to Medicare, Medicaid, MediGap, CHAMPUS, TRICARE, Veterans Affairs (VA), or Department of Defense (DoD) programs; patients who move from commercial to state or federal healthcare program insurance will no longer be eligible
- Cash-paying patients are not eligible for co-pay assistance
Program Benefits
- Eligible patients with an activated co-pay card and a valid prescription may pay as little as $10 per 30-day supply; monthly, annual, and/or per-claim maximum program benefits may apply; max benefits and co-pay redemption methods may vary from patient to patient and over time, depending on the terms of a patient’s prescription drug plan and to ensure that the funds are used for the benefit of the patient, based on factors determined solely by Bristol Myers Squibb (BMS).
- Some prescription drug plans have established programs referred to as ‘co-pay maximizer’ programs. A co-pay maximizer program is one in which the amount of the patient’s out-of-pocket costs is adjusted to reflect the availability of support offered by a co-pay support program. Patients enrolled in co-pay maximizer programs may receive program benefits that vary over time to ensure the program funds are used for the benefit of the patient.
Program Timing
- Patients will be evaluated for ongoing eligibility to continue enrollment in the program. In the event patients experience a change in insurance coverage or BMS makes changes to the copay assistance program, patients may be required to re-enroll into the program and provide updated insurance information to determine eligibility.
Additional Terms & Conditions
- Patients, pharmacists, and prescribers may not seek reimbursement from health insurance, health savings or flexible spending accounts, or any third party, for any part of the benefit received by the patient through this offer
- Acceptance of this offer confirms that this offer is consistent with patient’s insurance. Patients, pharmacists, and healthcare providers must report the receipt of co-pay assistance benefits if required by patient’s insurance provider
- All Program payments are for the benefit of the patient only
- Offer valid only in the United States and United States Territories. Void where prohibited by law, taxed, or restricted
- The Program is limited to one per patient. This offer cannot be combined with any other offer, rebate, coupon, or free trial
- This Program is not insurance, not transferable and not conditioned on any past, present, or future purchase, including refills
- No membership fees
- BMS reserves the right to rescind, revoke, or amend this offer at any time without notice
CV-US-2500076 03/25
CAMZYOS® (mavacamten) Bridge Program Terms & Conditions
Eligibility Requirements
- Patients must have commercial (private) insurance and must be treated with CAMZYOS for an on-label indication
- Patients must be 18 years of age or older
- Patients must live in the United States or United States territories
- Patients are not eligible if they have medical insurance coverage through a state or federal healthcare program, including but not limited to Medicare, Medicaid, MediGap, CHAMPUS, TRICARE, Veterans Affairs (VA), or Department of Defense (DoD) programs; patients who move from commercial plans to state or federal healthcare programs will no longer be eligible
Program Benefits
- If a coverage determination is delayed for twenty (20) calendar days or more, the patient will be provided CAMZYOS at no cost until coverage is received, a prior authorization is denied and not appealed, or for 18 dispenses, whichever is earlier
Program Timing
- Patients will be evaluated for ongoing eligibility and may not exceed 18 dispenses.
Additional Terms & Conditions
- An appeal of any prior authorization denial must be made within 60 days of prior authorization denial date or as per payer guidelines to remain in the Program
- Patients continuing into the following year will be re-verified for eligibility in January. A new prior authorization may be required and must be submitted within 30 days for patients to continue in the Program.
- Program reserves the right to re-verify patient’s insurance coverage at any point during the patient’s participation in the Program
- No claim for reimbursement for product dispensed pursuant to this offer may be made to any third-party payer
- Valid only in the United States and United States territories
- Other restrictions may apply
- The Program is not insurance, not transferable and not conditioned on any past, present, or future purchase
- Bristol Myers Squibb reserves the right to modify or discontinue this offer at any time without notice
CV-US-2300514 11/23
CAMZYOS® (mavacamten) Free 35-Day Trial Offer Program Terms & Conditions
Eligibility Requirements:
- Patients must not have previously filled a prescription for CAMZYOS
- Patient must have a valid 35-day prescription for CAMZYOS for an on-label indication
- Patients must be 18 years of age or older
- Patients must live in the United States or a US territory
Program Benefits
- Eligible patients with a valid 35-day prescription for CAMZYOS can receive a free 35-day supply of CAMZYOS. Patient is responsible for applicable taxes, if any. This offer may not be redeemed on prescriptions written for longer than 35 days.
- This offer is limited to one use per patient per lifetime and is non-transferrable. By redeeming this offer, the patient certifies that they have not previously filled a prescription for CAMZYOS.
- The Free 35-Day Trial for the specified prescription cannot be combined with any other rebate/coupon, free trial or similar offer. No substitutions are permitted.
Additional Terms & Conditions
- Patients, pharmacists, and prescribers cannot seek reimbursement for the Free 35-Day Trial of CAMZYOS from health insurance or any third party, including state or federally funded programs.
- Patients may not count the Free 35-Day Trial of CAMZYOS as an expense incurred for purposes of determining out-of-pocket costs for any plan, including true out-of-pocket costs (TrOOP), for purposes of calculating the out-of-pocket threshold for Medicare Part D plans.
- Only valid in the United States and US Territories; this offer is void where restricted or prohibited by law.
- The Program is not insurance, not transferable and not conditioned on any past, present, or future purchase
- Bristol Myers Squibb reserve the right to rescind, revoke or amend this offer at any time without notice.
CV-US-2500077 03/25
CAMZYOS® (mavacamten) Echocardiogram Co-Pay Assistance Program Terms & Conditions
Eligibility Requirements
- Patients must have commercial (private) insurance and must be treated with CAMZYOS for an on-label indication
- Patients must be 18 years of age or older
- Patients must live in the United States or United States territories
- Patients are not eligible if they have medical insurance coverage through a state or federal healthcare program, including but not limited to Medicare, Medicaid, MediGap, CHAMPUS, TRICARE, Veterans Affairs (VA), or Department of Defense (DoD) programs; patients who move from commercial plans to state or federal healthcare programs will no longer be eligible
- Patients residing in Massachusetts, Minnesota, or Rhode Island are not eligible
Program Benefits
- The Program includes a medical benefit offer for reimbursement of patient’s out-of-pocket costs for required echocardiogram procedures where the full cost is not covered by the patient’s insurance; program does not reimburse for other associated costs such as supplies, office visits or physician related services including interpretation of echocardiograms
- Patients may pay as little as $0 in out-of-pocket costs per echocardiogram procedure, subject to an annual maximum benefit of $2,500. Patients are responsible for any costs that exceed the maximum benefit
- To receive the Program benefits, a claim must be submitted within 180 days from the date of the Explanation of Benefits (EOB)
- The program may apply retroactively to out-of-pocket costs for echocardiograms that occurred within 180 days prior to the date of enrollment
- All Program payments are for the benefit of the patient only
Program Timing
- Patients will be evaluated for ongoing eligibility and will continue enrollment in the program if all eligibility requirements are met
Additional Terms & Conditions
- Patients and prescribers may not seek reimbursement from health insurance, health savings, or flexible spending accounts, or any third party, for any part of the benefit received by the patient through this offer
- Acceptance of this offer confirms that this offer is consistent with patient’s insurance. Patients and healthcare providers must report the receipt of co-pay assistance benefits if required by patient’s insurance provider
- Offer valid only in the United States and United States Territories. Void where prohibited by law, taxed, or restricted
- The Program is not insurance, not transferable and not conditioned on any past, present, or future purchase
- No membership fees
- Bristol Myers Squibb reserves the right to rescind, revoke, or amend this offer at any time without notice
CV-US-2300295 07/23
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