Terms and Conditions

This Agreement (the “Agreement”) governs your (“Patient”) and the pharmacy’s (“Pharmacy,” “You” or “Your”) participation in the below-referenced program, the MyVTAMA™ Program (“Program”). The Program is offered by Dermavant Sciences, Inc., (“Dermavant”). Throughout this Agreement, Dermavant and Pharmacy may be referred to individually as a “Party” or collectively as “Parties.” Program Details:

The Program is brought to you by Dermavant. The Program is available for commercially insured patients. Patients who are enrolled in a government-run or government-sponsored healthcare plan with a pharmacy benefit are not eligible to use the MyVTAMA Patient Savings Card (“Card”). This Card provides savings on out-of-pocket expenses for up to a 90-day supply of included Dermavant products subject to a maximum savings limit of wholesale acquisition cost plus usual and customary pharmacy charges, as described below. Maximum day supply limit may vary. If you have valid prescriptions for more than one Dermavant product, the copay expense and savings apply to each product. You may use this Card once every 25 days, depending on when you last received a 30-day supply of each Dermavant product. Use of this Card does not obligate you to use or to continue using any Dermavant product. You may use this Card at any participating pharmacy located in the United States.

This Card may not be combined with any savings, discount, free trial, or other similar offer for the same prescription. You must meet the eligibility criteria in these Terms and Conditions every time you use the Card. This Card is not transferable and is void if reproduced. This Card is not health insurance. Limit one (1) Card per patient per use. This Card has no cash value and will not be accepted outside of participating pharmacies in the United States. Please visit Dermavant’s website for our privacy practices. Card benefits are not available for patient costs incurred prior to the date patient is determined to be eligible for MyVTAMA. The Card is void where prohibited by law, taxed, or restricted.

Use of this Card is subject to applicable state and federal law, and is void where prohibited by law, rule or regulation. In the event a lower cost generic drug that the FDA had designated as a therapeutically equivalent product is available for one of the Dermavant products covered by this Card, or if the active ingredient of a Dermavant product is available at a lower cost without a prescription, this offer will become void in California with respect to the Dermavant product.

Dermavant reserves the right to rescind, revoke, or amend these terms and conditions at any time , and to deny payment for noncompliance with these terms and conditions in its sole discretion.

Minimum out-of-pocket-expenses:

Eligible commercially insured patients are responsible for paying out-of-pocket expenses and any amount that exceeds the Dermavant payment for each prescription, as follows:

Use of this Card may be subject to limitations imposed by state or federal law, or by your health insurer. This Card is not valid where prohibited by law or by your health insurer.

The MyVTAMA program is only available for commercially insured patients. Patients who are enrolled in Medicare Part D, Medicaid, Medigap, VA, DoD, TRICARE, or any other government-run or government-sponsored healthcare program with a pharmacy benefit (“Government Beneficiary”) are not eligible to use the Card.

Patient Instructions:

You must present this card to the pharmacist along with your prescription each time you fill your prescription to participate in the Program. If you have any questions regarding your eligibility or benefits or if you wish to discontinue your participation, call the Dermavant Savings Program customer support at 347-532-5250 (9:00 AM-7:00 PM EST, Monday-Sunday).

When you use this Card, you are certifying that you understand the Program rules, regulations, and these terms and conditions which are also set forth at www.VTAMA.com/terms-conditions, and that you will comply with them. You are not eligible if you are a Government Beneficiary. No purchase is necessary and there are no membership fees. You may not use this Card if prohibited by your insurer. You are responsible for any reporting for the use of this Card as required by your insurer.

You may apply for this Card for yourself, if you are 18 years of age or older, or on behalf of a minor child 2 years of age or older (the “Child”). By using this Card, you acknowledge that you or the Child currently meet the following eligibility criteria:

You/the Child have a valid prescription for the Dermavant product your copay and the savings apply to and that prescription is for an FDA-approved indication;
You/the Child are subject to a private insurance copay requirement for your prescription;
You/the Child are not a Government Beneficiary;
You are at least 18 years old;
You/the Child reside in the United States.

Pharmacist Instructions:

When you accept/use this Card, you are certifying that you have not submitted and will not submit a claim for reimbursement under Medicare Part D, Medicaid, Medigap, VA, DoD, TRICARE or any other government-run or government-sponsored healthcare program with a pharmacy benefit for this prescription and that you agree to and understand the Program rules, regulations, and these terms and conditions which are also set forth at www.VTAMA.com/terms-conditions, and that you will comply with them. By accepting/using this Card, you acknowledge and agree to/that:

Submit transaction to Pharmacy Data Management Inc. (PDMI), using Bin #610020. Pharmacy participation, payments, and reimbursement are subject to terms and conditions negotiated between PDMI and the Pharmacy. For questions regarding PDMI processing, setup, claims transmission, patient eligibility, or other issues, please call 1-800-800-7364.
If commercial prescription insurance exists, you shall run the commercial prescription insurance as primary insurance, input Card information as secondary coverage, and transmit using the COB segment of the NCPDP transaction. Applicable discounts will be displayed in the transaction response;
Acceptance of this Card and your submission of claims for the Program are subject to our Card administrator, Apollo. Apollo program Terms and Conditions posted at apollocare.com/dermavant-copay-terms/;
Patient is not eligible if patient is a Government Beneficiary or where prohibited by law; and
If you are filling a prescription in the state of California, in the event a lower generic drug that the FDA has designated as a therapeutically equivalent product becomes available for one of the Dermavant products covered by this Card, or if the active ingredient of a Dermavant product is available at a lower cost without a prescription, this offer is void with respect to that Dermavant product and you agree not to apply this Card to any discount or savings to such patient under the Program for such Dermavant product.

No Warranties:

PHARMACY AGREES THAT ITS PARTICIPATION IN THE PROGRAM IS STRICTLY VOLUNTARY AND AT PHARMACY’S OWN RISK. PHARMACY UNDERSTANDS AND AGREES THAT DERMVANT, ITS ADMINISTRATOR OF THE CARD, AND PATIENTS DISCLAIM ANY AND ALL WARRANTIES, REPRESENTATIONS AND CONDITIONS, WHETHER EXPRESS OR IMPLIED, WITH RESPECT TO THE PROGRAM AND PHARMACY’S PARTICIPATION IN IT. PHARMACY FURTHER UNDERSTANDS AND AGREES THAT, EXCEPT FOR THE AMOUNT DUE TO PHARMACY, AS DEFINED HEREIN, PHARMACY IS NOT ENTITLED TO PAYMENT OR COMPENSATION OF ANY KIND.

Indemnification:

Pharmacy will make no representations or warranties of any kind on behalf of Dermavant, its Administrator of the Card, their respective products or Program, or patients. Dermavant will not be liable for any claim, injury, demand or judgment based on tort or other grounds (including, without limitation, warranty of merchantability) arising out of the sale or dispensing of any prescription drug provided by Pharmacy to any person arising out of Pharmacy’s negligence, violation of law, or willful misconduct; and Pharmacy agrees to defend Dermavant and indemnify and hold Dermavant harmless from and against any and all such claims, injuries, demands and judgments, including, without limitation, payment of all costs and attorneys’ fees.

Limitation of Liability:

PHARMACY UNDERSTANDS AND AGREES THAT IN NO EVENT WILL DERMAVANT, ITS ADMINISTRATOR OF THE CARD, PATIENTS, OR THEIR RESPECTIVE OFFICERS, DIRECTORS, SUBSIDIARIES, AFFILIATES, OR SUPPLIERS BE LIABLE FOR DAMAGES OF ANY KIND, WHETHER DIRECT, INDIRECT, CONSEQUENTIAL, INCIDENTAL, PUNITIVE, OR OTHERWISE, HOWEVER CAUSED AND REGARDLESS OF THE THEORY OF LIABILITY, ARISING OUT OF THESE TERMS AND CONDITIONS OR PHARMACY’S PARTICIPATION IN THE PROGRAM, EVEN IF DERMAVANT HAS BEEN INFORMED OF THE POSSIBILITY OF SUCH DAMAGES.

Audit and Review Rights:

Dermavant or its designee will have the right upon prior written notice, and during normal business hours, during Pharmacy’s participation in the Program and for a period of two (2) years thereafter, subject to applicable law (including those governing confidentiality), to audit or review Pharmacy’s records as they pertain to Pharmacy’s compliance with this Agreement. In the event that any such audit or review reveals any erroneous amounts paid to Pharmacy, Pharmacy agrees to pay Dermavant any such amounts within fifteen (15) calendar days of written demand by Dermavant. Pharmacy shall provide access to records or requested records within a reasonable period of time not to exceed fifteen (15) business days, unless a longer period of time is agreed to by the Parties in writing. The rights provided in this Section will be cumulative and in addition to any other rights or remedies that may be available to Dermavant.

Venue:

Acceptance and participation in the Program and/or the use of this Card constitutes an agreement with Dermavant in Texas and the transactions underlying the participation in the Program and use of this Card is performable for all purposes in Texas. By participating in the Program and using this Card, you agree that the transaction has a reasonable relationship to the State of Texas in that, among other things, this Card and the Program originated from the State of Texas and Dermavant will perform a substantial part of its respective obligations in the State of Texas. It is agreed that the exclusive venue for any dispute arising out of participation in the Program and/or this Card is a state or federal court of competent jurisdiction in Tarrant County, Texas. By participating in Program and using this Card, you irrevocably and unconditionally submit to the exclusive jurisdiction of a state or federal court in Tarrant County, Texas.

Governing Law:

You consent to the Program and use of this Card being governed by and interpreted in accordance with the substantive laws of the State of Texas without regard to its conflict of law principles.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.

Terms and Conditions