My QUTENZA Connect Cost Savings Program^*

Patients may be eligible for the cost savings program if they:

• Are using QUTENZA for an FDA-approved use
• Are 18 years of age or older
• Have commercial (private) insurance that covers QUTENZA
• Live and receive treatment in the United States
• Do not use a state or federal healthcare plan to pay for their medication – this includes, but is not limited to, Medicare, Medicaid, and TRICARE

Benefit:

• Eligible patients may pay as little as $0, with a maximum annual benefit of $5,000
• Eligible patients may receive up to $1,500 per year for in-office administration costs

Questions:

• For questions regarding the My QUTENZA Connect Cost Savings Program, please call 1-833-295-3579

*Eligibility Criteria, Terms, and Conditions:

1. The My QUTENZA Connect Cost Savings Program (the “Program”) is available only to eligible adult patients prescribed QUTENZA for use consistent with approved indications in US product labeling for QUTENZA. Eligible patients must reside in the US, Puerto Rico, or the US territories based on the patient’s address and must be insured by a commercial insurer that covers QUTENZA and does not prohibit participation in patient assistance programs. Uninsured or cash-paying patients and patients with coverage for QUTENZA through federal- or state-funded government healthcare programs, including Medicare, Medicaid, Medigap, TRICARE, Veterans Affairs (VA), or Department of Defense (DoD), are not eligible for the Program, with the exception of the Federal Employees Health Benefit (FEHB) Program for the purpose of this Program. A patient who begins receiving benefits for QUTENZA from a government healthcare program will no longer be eligible for the Program.
2. This Program will only accept applications by mail. No phone or email requests will be accepted or honored. Applications must be fully completed based on the instructions stated on the registration form. Averitas Pharma, Inc., is not responsible for lost, late, damaged, misdirected, incomplete, or illegible submissions. All submissions become the property of Averitas Pharma, Inc., and its agents. Please retain copies of any materials you submit.
3. Any refund under this Program may not exceed the eligible patient’s medication and/or administration co-payment, co-insurance, or deductible costs (“Patient Responsibility”) for QUTENZA, whether covered under the medical or pharmacy benefit. For pharmacy claims associated with the medication, this offer can be used only with a valid QUTENZA prescription at the time the prescription is filled by the pharmacist and dispensed to the patient, and is good only at participating pharmacies in the US.
4. The Program is valid for the patient’s out-of-pocket costs for the medication and cannot be used if the patient is eligible to be reimbursed for the entire cost of QUTENZA. The patient and patient’s healthcare provider may not seek any other reimbursement of Patient Responsibility for the medication.
5. The Program is valid for the patient’s total out-of-pocket costs for the administration of QUTENZA and cannot be used if the patient is eligible to be reimbursed for the cost of the administration of QUTENZA. The patient and the patient’s healthcare provider may not seek other reimbursement of Patient Responsibility for the administration of QUTENZA. Applications for the full refund for the administration of QUTENZA are not eligible for the Program and will not be approved if the healthcare provider’s administration costs are not covered or reimbursed by the patient’s insurance.
6. Patient Responsibility for the medication must be isolated on the claim and separate from other services and products. A patient may not apply for reimbursement of Patient Responsibility under the Program if the patient’s healthcare provider has already sought reimbursement under the Program, and the patient’s healthcare provider may not seek such reimbursement of Patient Responsibility under the Program if the patient has already applied for reimbursement under the Program.
7. Refunds will be processed in the order in which they are received. Approved claims will be processed and paid in the subsequent billing cycle. Please allow approximately 4 weeks for delivery of refund checks. Tampering with, altering, or falsifying payment information is prohibited by law.
8. The Program is effective as of January 1, 2024, for treatments administered after this date. This offer is limited to 1 per person, is nontransferable, and is valid for the eligible patient only. No other purchase is necessary. This offer has no cash value and cannot be combined with any other patient assistance program, free trial, discount, prescription savings card, or other offer. Averitas Pharma, Inc., reserves the right to cancel, modify, or rescind this Program at any time. Aggregate and non-identifiable patient information may be used by Averitas Pharma, Inc., for market research and other related purposes. This Program is not insurance and is not intended to substitute for insurance. This offer is void where prohibited or restricted by law.