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Chiesi Total Care Copay Assistance Program Terms and Conditions - Ferriprox^® (deferiprone)

The Chiesi Total Care Copay Assistance Program (the “Copay Program”) may pay for eligible out-of-pocket medication, up to $10,000 per calendar year. After reaching the maximum Copay Program benefit, the patient will be responsible for any remaining out-of-pocket costs incurred during that calendar year.

The Copay Program is valid only for patients with commercial insurance who have a valid prescription for a US Food and Drug Administration (FDA)-approved indication for the product. A patient who receives healthcare benefits under any plan or program funded in whole or in part by federal or state governments including Medicare, Medicaid, TRICARE, Veterans Affairs (VA), State Prescription Assistance Plans (SPAPs) (other than health insurance for federal government employees) or any state healthcare program such as Medicaid, Children’s Health Insurance Program, programs funded under Maternal and Child Health Program or programs funded under Social Services Block Grant are not eligible for the Copay Program. A patient covered under a commercial health plan purchased through a health insurance marketplace or exchange is not a Government Program Beneficiary even if the costs of such coverage are subsidized by the federal government.

To enroll in the Copay Program, the patient must also enroll in Chiesi Total Care, a patient support services program offered by Chiesi. The patient must also be a resident of the US or one of its territories. If the Patient is incapable of acting on their own behalf or if the Patient is under 18 years old, enrollment into Chiesi Total Care may be completed by another person acting on their behalf (such as a caregiver).

If at any time a patient begins receiving prescription drug coverage under any such federal, state, or government-funded healthcare program, patient will no longer be able to participate in the Copay Program and patient must notify Chiesi Total Care to stop participation.

Patients residing in or receiving treatment in certain states may not be eligible for the Copay Program. Copay Program not available in California or Massachusetts when an AB-rated equivalent to the product is commercially available. Patients may not seek reimbursement for value received from Chiesi Total Care or from the Copay Program. The Copay Program does not obligate the use of any specific medication or healthcare provider. Participation in the Copay Program is not conditioned on any past, present, or future purchase.

The Copay Program benefits may not be sold, purchased, traded, or offered for sale, purchase, or trade. The Copay Program is not valid where prohibited by law, taxed, or otherwise restricted. Offer subject to change or discontinuance without notice. Restrictions, including monthly maximums, may apply. This is not health insurance.

This is a voluntary program. Patients who choose not to enroll in the Copay Program will still be able to receive medication. Patients may participate in Chiesi Total Care without participating in the Copay Program. After enrolling in the Copay Program or in Chiesi Total Care, participants may opt out by contacting Chiesi Total Care, as outlined in the Chiesi Total Care Enrollment and Authorization Form. Patients must renew their eligibility by December 31 of each year to continue to receive support under the Copay Program.

By participating in the Copay Program, participants acknowledge that they understand and agree to comply with these Terms and Conditions.