Eligibility Rules and Regulations

Eligibility Rules

• The CABENUVA Patient Savings Program (the "Program") helps commercially insured Patients in the United States (including the United States territories) who are prescribed CABENUVA pay for their eligible out-of-pocket costs.
• Patients must have commercial insurance that covers CABENUVA. This Program is NOT available for Patients with commercial insurance that does NOT cover CABENUVA. Uninsured Patients or Patients paying cash for CABENUVA are also NOT eligible for this Program.
• This Program is not available for Patients enrolled in any federal or state healthcare program, including, but not limited to, Medicare, Medicaid, Medigap, Department of Defense (DoD), Veterans Affairs (VA), TRICARE, Puerto Rico Government Insurance, or any state Patient or pharmaceutical assistance programs.
• Patients who are Medicare eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees (i.e., you are eligible for Medicare Part D but receive a prescription drug benefit through a former employer) are NOT eligible for this Program. Patients who move from commercial to state or federally funded insurance will no longer be eligible for the Program.
• This Program is NOT health insurance.

Terms of Use

• Eligible Patients may pay as little as $0 on each prescription fill. Further, Eligible Patients may also receive assistance with the Patient's out-of-pocket costs associated with the administration of CABENUVA of up to $100 per treatment (maximum of 13 eligible dates of service in 12-month period) administration costs. Residents of Massachusetts, Rhode Island, and Minnesota are not eligible for assistance with injection administration out-of-pocket costs. The Program has a maximum annual limit of $13,000 and includes both the Patient’s out-of-pocket medication costs as well as the injection administration costs.
• Each Eligible Patient is responsible for their out-of-pocket costs for CABENUVA exceeding the program limits. Eligible Patients enrolled in the Program will be automatically enrolled in the Program for the next calendar year unless they opt out of the Program or their insurance coverage changes such that the Patient no longer satisfies eligibility requirements for Program participation.
• Healthcare Providers must first submit a primary claim for product and administration costs for CABENUVA to the Patient's commercial insurance plan and receive an Explanation of Benefits from the insurer. A secondary claim can then be submitted to the Program using a standard 1500 health insurance claim form. The Explanation of Benefits from the Patient's commercial insurance plan detailing their out-of-pocket costs for CABENUVA must be included. All CABENUVA claims must be submitted within 180 days of insurance payment to receive payment from the Program.
• The Program may apply to eligible out-of-pocket costs incurred by the Patient for CABENUVA within 180 days prior to the date an Eligible Patient is enrolled in the Program, subject to annual Program maximum and the applicable Terms and Conditions based on CABENUVA administration date.
• Patient or provider may contact ViiVConnect at 1-844-588-3288 (toll free) for more information.
• All coverage requirements mandated by the Eligible Patient's commercial insurance company must be satisfied in order for the Program to take effect. When submitting claims under this Program, Eligible Patients and their treating providers are certifying that they understand the Program rules, regulations, and Terms and Conditions, and comply with the Program terms as set forth herein. Specifically, you, as an Eligible Patient, are certifying that a claim has not been submitted under a state or federally funded healthcare program, including but not limited to, Medicare, Medicare Advantage Plans, Medicare Part D, Medicaid, Medigap, VA, DoD, TRICARE, and the Puerto Rico Government Insurance Plan.
• All applicable information requested by the Program must be provided, and all certifications must be signed. Any requests for Program assistance which do not contain all the necessary information will not be eligible for benefits under the Program.
• This Program is NOT health insurance.

Void if copied, transferred, purchased, altered or traded, and where prohibited and restricted by law.

The Program is not transferable. No substitutions are permitted. The Program form may not be sold, purchased, traded, or counterfeited. Void if reproduced. The Program benefit cannot be combined with any other financial assistance program, free trial, discount, prescription savings card, or other offer.

Data related to an Eligible Patient's receipt of Program benefits may be collected, analyzed, and shared with ViiV Healthcare group of companies and its affiliates, for conducting data analytics, market research, and Program related business activities.

ViiV Healthcare group of companies and its affiliates reserves the right to make eligibility determinations, to set Program benefit maximums, to monitor participation, and to change, rescind, revoke, or discontinue this Program at any time without notice. Limit one Program enrollment per individual.

If you have any questions regarding this Program, your eligibility or benefits, or if you wish to discontinue your participation, call ViiVConnect at 1-844-588-3288 (toll free), Monday - Friday, 8AM - 11PM (ET).