Patients must be residents of the United States or US Territories. The Bridge Program is not available for patients whose prescription claims are reimbursed, in whole or in part, by any state or federal government program, including, but not limited to, Medicaid, Medicare, Medigap, Department of Defense (DoD), Veterans Affairs (VA), TRICARE, Puerto Rico Government insurance, or any state patient or pharmaceutical assistance program. Patients will receive their maintenance drug supply each month for up to 4 months or until they receive insurance coverage approval, whichever occurs earlier. By participating, patient acknowledges intent to pursue insurance coverage for ORGOVYX with their healthcare provider. Prescribers must complete the Bridge Program prescription on the start form. †The ORGOVYX Bridge Program ("Bridge Program") provides ORGOVYX at no cost for a limited period (up to 4 months) in a calendar year to eligible, commercially-insured patients, who have been prescribed ORGOVYX for an FDA-approved indication, and whose insurance coverage is delayed or who experience a temporary lapse in coverage. ORGOVYX BRIDGE PROGRAM: TERMS AND CONDITIONS The ORGOVYX Copay Program is valid through December 31, 2024. Myovant Sciences reserves the right to revoke, rescind, or amend this offer without notice. Patient and participating pharmacists agree to report the receipt of Copay Program benefits to any insurer or other third party who pays for or reimburses any part of the prescription filled using the Card, as may be required by such insurer or third party. Patient and participating pharmacists agree not to seek reimbursement for all, or any part of the benefit received by the patient through this Copay Program. This offer is not conditioned on any past, present, or future purchase, including refills. This offer cannot be combined with any other coupon, free trial, discount, prescription savings card, or other offer. This Copay Program is void where prohibited by state law and on the date an AB generic equivalent for ORGOVYX becomes available. Patient must be a resident of the U.S., Puerto Rico, or U.S. Offer is not valid for cash-paying patients. The Copay Program is not valid for patients whose prescription claims are reimbursed, in whole or in part, by any state or federal government program, including, but not limited to, Medicaid, Medicare, Medigap, Department of Defense (DoD), Veterans Affairs (VA), TRICARE, Puerto Rico Government Insurance, or any state patient or pharmaceutical assistance program. This Copay Program may not be redeemed more than once per 21 days. After the annual maximum of $10,000 for ORGOVYX is reached, patient will be responsible for the remaining monthly out-of-pocket costs. With this Copay Program, eligible patients will pay as little as $10 per month, subject to a maximum of $10,000 per calendar year. *The ORGOVYX Copay Assistance Program (“Copay Program”) is for eligible patients with commercial prescription insurance for ORGOVYX. ORGOVYX COPAY ASSISTANCE PROGRAM: TERMS AND CONDITIONS
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