Welcome to the ERZOFRI^® patient site

Eligibility Requirements:

Eligibility Criteria: Subject to program limitations and terms and conditions, the ERZOFRI^® Copay Card Program, also referred to simply as the ERZOFRI^® Copay Card, is open to patients who have a valid prescription for ERZOFRI^® and who have commercial or private insurance that covers ERZOFRI^®, including state and federal plans commonly referred to as “healthcare exchange plans.” No substitutions for ERZOFRI^® are permitted.

• Eligible patients must be over the age of 18 and have commercial prescription insurance administered through a pharmacy or medical benefit plan.
• Uninsured patients are NOT eligible to be enrolled in this copay program.
• This copay program will pay for the out-of-pocket copay payments otherwise due from eligible patients for prescription drug coverage related to ERZOFRI^®, up to the program limits.
• This copay program does not cover any copays or other costs related to medical office visits or administration of ERZOFRI^®.
• There are no income requirements for patients to qualify for this program.
• This offer is not valid for patients whose coverage for ERZOFRI^® is paid for in whole or in part by Medicare, Medicaid, or any other federal or state healthcare program such as VA, TRICARE or DOD.
• This program is not valid for cash-paying patients.
• Cash Discount Cards and other non-insurance plans are NOT valid as primary insurance under this program.
• This program is restricted to residents of the United States.
• Patients residing in or receiving treatment in certain states may not be eligible.
• Eligible patients may pay as little as $10 for once-monthly injections of ERZOFRI^®.
• Maximum annual benefit of $8000 per individual applies and out-of-pocket expenses may vary. Patients are responsible for costs above maximum benefit amounts.

Other Terms and Conditions:

• Patients with managed care requirements (e.g., prior authorization, step edit) must fulfill those requirements before they can be considered for enrollment.
• To enroll in this program, patients will be required to provide personal information that includes name, home address, email address, phone number, and other information, including prescription and insurance information. This information is needed for Luye Pharma Group Ltd. and its affiliates to enroll you in the ERZOFRI^® Copay Card Program. The use of your information will be governed by the Luye Pharma Group Ltd. Privacy Policy.
• If a patient begins receiving coverage for prescriptions under any federal, state, or government healthcare program (including but not limited to Medicare, Medicaid, TRICARE, Department of Defense, or Veteran Affairs programs), the patient will no longer qualify for this program and must contact the ERZOFRI^® Copay Card Program at (844) 463-0375 to stop participation in this program.
• If the pharmacy cannot process the ERZOFRI^® Copay Card, patients may still be able to receive a rebate by submitting a rebate request. Rebate requests must be submitted within 180 days of the date of service.

Additional Limitations:

The ERZOFRI^® Copay Card is intended for the benefit of patients, not their insurance plans, pharmacy benefit managers, or other third parties (“Plan Administrators”). Patients whose commercial insurance plans or plan sponsors implement the following types of programs may not be eligible for the ERZOFRI^® Copay Card, or have a reduced annual maximum ERZOFRI^® Copay Card benefit:

• Programs that do not apply ERZOFRI^® Copay Card payments to satisfy patient out-of-pocket cost sharing amounts (e.g., accumulator programs); or
• Programs that require the patient’s use of the ERZOFRI^® Copay Card as a condition of the plan waiving some or all of otherwise applicable patient out-of-pocket cost sharing amounts (e.g., maximizer programs).

If you believe your commercial insurance plan may have such programs in place, please call (844) 463-0375. Plan Administrators are prohibited from applying for, or assisting with, the enrollment of patients for the ERZOFRI^® Copay Card benefits. The patient or their legal representative must personally enroll in the ERZOFRI^® Copay Card to be eligible for benefits.

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 offers.

This program is managed by Paysign on behalf of Luye Pharma Group Ltd. and Luye Pharma Group Ltd. 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. This program expires December 31, 2025.

If you have any questions regarding this program, your eligibility, or benefits, or if you wish to discontinue your participation, please call (844) 463-0375, Monday-Friday, 8 AM-8 PM EST, excluding holidays.

For the Patient:

As a patient, you must not seek reimbursement for the value received from this ERZOFRI^® Copay Card from any third-party payers, including a flexible spending account or healthcare savings account. Participating in this program means that you acknowledge that you are eligible for this program and agree to comply with the terms and conditions. You are also ensuring you comply with any required disclosure regarding your participation in this program to your insurance carrier or pharmacy benefit manager. The ERZOFRI^® Copay Card offer must be presented along with your valid ERZOFRI^® prescription and your primary insurance card to participate in this program.

Restrictions may apply. Offer subject to change or discontinuation without notice. This is not health insurance. This program is for eligible Commercially Insured Patients only. Uninsured or cash-paying patients are not eligible for this copay program.

You, the patient, may pay as little as $10 once monthly for your ERZOFRI^® injections. Your maximum program assistance per prescription and annual benefit limits per patient apply and out-of-pocket expenses may vary.

For the Pharmacist:

When you apply for this program, you confirm that ERZOFRI^® is being provided to an eligible commercially insured patient according to the specified terms and conditions, and the pharmacy has not, and will not, submit a claim for reimbursement under any federal, state, or other government program for this prescription.

For patients with commercial insurance, first submit the claim to the primary third-party payer. Afterward, send the remaining balance to Pharmacy Data Management, Inc. (PDMI) as a secondary payer coordination of benefits (COB) with patient responsibility and a valid other coverage code (e.g., 08). If the primary claim is denied by the insurer due to a prior authorization (PA) requirement, please initiate the PA process to assist your patient in saving on prescriptions for ERZOFRI^®.

For any questions, please contact the copay support program line at (844) 463-0375, Monday-Friday, 8AM-8PM EST.

Please see full Prescribing Information for ERZOFRI^®, including Boxed WARNING.