SYMBRAVO^® (meloxicam and rizatriptan)
Copay Terms and Conditions

This SYMBRAVO Copay Assistance Program is designed to assist eligible commercially insured patients who have been prescribed an Axsome medicine for an FDA-approved indication.

Patient Benefit:

• Eligible patients will pay as little as $0 with a valid prescription for an FDA approved indication; monthly, annual, and/or per-claim maximum program benefits may apply and vary depending on the patient's specific terms of their prescription drug plan and to ensure that the funds are used for the benefit of the patient, based on factors determined by Axsome.

Program Eligibility Requirements and Benefits:

• Patients must have commercial (private) health insurance. This program is not valid where the entire cost of the medication is reimbursed by insurance or where insurance does not cover the medication.
• Offer not valid for patients with prescription insurance through federal or state healthcare programs, including but not limited to, Medicaid, Medicare drug benefit plan, Tricare or other federal or state health programs (such as medical assistance programs).
• Some prescription drug plans have implemented programs commonly known as “copay maximizer” or “accumulator” programs. These programs adjust the patient's out-of-pocket cost to reflect the availability of financial support received from a copay support program, so that out-of-pocket payments that are subsidized by a manufacturer's copay program are not treated as a patient's out-of-pocket payments. Patients enrolled in these types of programs may receive benefits from the Axsome Copay Savings Program that vary over time to ensure funds are used for the benefit of the patient.
• Cash-paying patients are not eligible for copay assistance.
• This offer may not be redeemed for cash.
• Patient must be a resident of the United States or U.S. territories.
• Patient or patient's guardian must be 18 years of age or older.
• Patients with questions about the SYMBRAVO On My Side Savings Offer should call 1-800-805-8621

Additional Terms & Conditions of Program:

• By using this offer, the patient and pharmacist certify that the patient meets the eligibility criteria and will comply with all the terms and conditions.
• Cash Discount Cards and other non-insurance plans are not valid as primary insurer under this offer. If the patient is eligible for drug benefits under any such program, the patient cannot use this offer.
• This offer is not transferable and is limited to one offer per patient. This copay offer cannot be combined with any other savings, free trial or similar offer(s) for the specified prescription.
• Void where prohibited by law. Not valid if reproduced.
• This program is not insurance.
• Axsome Therapeutics reserves the right to rescind, revoke or amend this offer without notice at any time.

To the Pharmacist:

• When you apply this offer, you are certifying that you have not submitted a claim for reimbursement under any federal, state, or other governmental programs for this prescription.
• Participation in this program must comply with all applicable laws and regulations as a pharmacy provider. You are certifying that you will comply with the terms and conditions described in the Restrictions section.
• For commercially insured/covered claims:
  1. Submit the claim to the primary Third-Party Payer first.
  2. Submit the balance due to McKesson as a secondary claim with Other Coverage Code 08.
• For commercially insured/not covered claims:
  1. Submit the claim to the primary Third-Party Payer first.
  2. If the primary claim response shows a prior authorization is required, please initiate the appropriate prior authorization process before proceeding with processing.
  3. If the claim is not covered by the primary Third-Party Payer, submit a secondary claim to McKesson with Other Coverage Code 03.
• For any questions regarding online processing, call the pharmacy Help Desk at 1-888-215-8370

BY USING THIS CARD, YOU AND YOUR PHARMACIST UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS AND TERMS OF USE.