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Chiesi Total Care Terms and Conditions

These terms and conditions apply to the patient support services offered through the Chiesi Total Care Patient Support Program (the “Program”) for MYCAPSSA, unless otherwise noted. These patient support service programs may include affordability solutions support, appeals support, benefit verification, patient education support, copay assistance, patient assistance, and Pharmacist support. Patient support services offered through the Program are subject to change.

A patient who receives health care benefits under any plan or program funded in whole or in part by federal or state governments including Medicare, Medicare Part D, Medicare Advantage, Medigap, Medicaid, TRICARE, Veterans Affairs (VA), Department of Defense, State Prescription Assistance Plans (SPAPs) (other than health insurance for federal government employees) or any state health care 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 (collectively, “Government-funded Plans”) are not eligible for patient support services that provide financial support through the Program. Only patients with commercial insurance who have a valid prescription for a US Food and Drug Administration-approved indication for MYCAPSSA are eligible for patient support services that provide financial support through the Program.

To enroll in any of the patient support services of the Program, the patient must also enroll in Chiesi Total Care. The patient must 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 the Program may be completed by another person acting on their behalf (such as a parent or legal guardian).

If at any time a patient begins receiving prescription drug coverage under any Government-funded Plan, the patient will no longer be able to participate in the patient support services programs that provide financial support through the Program and the patient must notify the Program to stop participation.

Patients residing in or receiving treatment in certain states may not be eligible for the Copay Assistance Program. Patients may not seek reimbursement for value received from Copay Programs. The Copay Programs do not obligate the use of any specific medication or health care provider. Participation in a Copay Program is not conditioned on any past, present, or future purchase.

To determine financial eligibility for participation in the Patient Assistance Program, the patient will be asked to provide the size of the household, annual household income, and proof of income. Proof of income may include, among other things, W2 form(s), paycheck stubs, and/or prior year tax returns.

Other programs may be offered to eligible patients from time to time. Chiesi Total Care will notify the patient of programs for which they are eligible.

Program benefits may not be sold, purchased, traded, or offered for sale, purchase, or trade. The Chiesi Total Care patient support services are 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 any of the support programs will still be able to receive medication. Patients may participate in Chiesi Total Care without participating in a support program. After enrolling 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 Program.

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