QBREXZA Copay Card Terms and Conditions

The QBREXZA Copay Card is valid ONLY for patients with commercial (private or non-governmental) drug insurance. Patients enrolled in Medicare, Medicaid, Medigap, TRICARE®, the Department of Veterans Affairs healthcare program, or any other federal or state government-funded healthcare program (“Government Programs”) are not eligible. Patients who become enrolled in such Government Programs during their enrollment period will no longer be eligible for the program. Eligible patients must be residents of the United States, excluding territories, and the patient, or the patient’s parent or guardian, must be 18 years or older to receive Copay Card program assistance.

The copay card should only be used in treatments that are in accordance with the QBREXZA Prescribing Information found at pdf/qbrexza-pi.pdf.

Eligible patients with commercial prescription drug insurance coverage for QBREXZA may pay as little as $35 per fill (30-day supply). Individual patient savings are limited to $625 per fill (30-day supply) and $5,000 in maximum total savings per calendar year, January 1 – December 31. This Copay Card program is not health insurance or a benefit plan. Distribution or use of the copay card does not obligate use or continuing use of any specific product or provider. Patient or guardian is responsible for reporting the receipt of all copay card savings or reimbursement received to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the Copay Card program, as may be required.

The copay card is not valid for medications the patient receives for free or that are eligible to be reimbursed by private insurance plans or other healthcare or pharmaceutical assistance programs that reimburse the patient in part or for the entire cost of his/her Dermira medication. Patient, guardian, pharmacist, prescriber, and any other person using the copay card agree not to seek reimbursement for all or any part of the savings received by the recipient through the offer.

The copay card will be accepted by participating pharmacies in the United States. To qualify for this Copay Card program, the patient may be required to pay out-of-pocket expenses for each prescription. This copay card is only available with a valid prescription and cannot be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription. Use of this copay card must be consistent with all relevant health insurance requirements and payer agreements. Participating pharmacies are obligated to inform third-party payers about the use of the copay card as provided for under the applicable insurance or as otherwise required by contract or law. The copay card may not be sold, purchased, traded, or offered for sale, purchase, or trade. The copay card is limited to one per person during this offer period and is not transferable. Void where prohibited by law, taxed, or restricted.

This Copay Card program renews annually on January 1.

Dermira, Inc., a wholly-owned subsidiary of Eli Lilly and Company, reserves the right to rescind, revoke, amend, or terminate the program without notice at any time.

If you have questions or need additional support, call 1-877-DERMIRA (877-337-6472).